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

Housing insecurity, which includes lack of affordable housing, overcrowded living conditions, and homelessness [4], is a critical social determinant of health.[5] Social Determinants of Health (SDOH) are nonmedical factors in the environments where people are born, grow, work, live, and age that affects a wide range of health, functioning, and quality-of-life outcomes and risks.[6][7][8] Housing insecurity exposes individuals and families to increased stress and negatively affects mental and physical health.[4][9][10] Mental health and substance use disorders (MH/SUDs) impact a person’s ability to obtain or maintain housing, especially when faced with discrimination.[5]

The Fair Housing Act protects people from discrimination based on race, color, national origin, religion, sex, gender identity, sexual orientation, familial status, or disability when they are renting or buying a home, applying for a mortgage, seeking housing assistance, or engaging in other housing-related activities.[11] The number of housing discrimination complaints increased significantly in recent years.[12][13] Despite protections, people with MH/SUDs still face discrimination when searching for housing or requesting reasonable accommodations to provide equal opportunity in housing-related issues.[14][15][16]

Housing discrimination trends underscore the need for increased funding to support fair housing efforts.[13] Congress should pass the Housing Fairness Act to address discriminatory practices that affect those with disabilities, including MH/SUDs.

Housing insecurity, which includes lack of affordable housing, overcrowding living conditions, and homelessness,[4][5] exposes individuals and families to increased stress, negatively impacting mental and physical health.[4][6][7] Mental health and substance use disorders (MH/SUDs) impact a person’s ability to obtain or maintain housing, especially when faced with discrimination.[5] Research overwhelmingly demonstrates that supportive housing—including Housing First[8][9]—improves individual outcomes, enhances communities, and saves public dollars.[1]

The Centers for Medicare and Medicaid Services issued updated guidance on Medicaid waivers, allowing states to use Medicaid funding to support housing expenses like rent and temporary housing.[10] Rent subsidies provided to individuals experiencing homelessness were found to improve reported mental health and reduce both emergency department visits and use of crisis stabilization services.[10] Congress should allow Medicaid to reimburse housing authorities for training and education about housing insecurity,[2] provide incentives in Medicaid funding to coordinate comprehensive support for housing placements,[2], and allow states to fund transitional housing for individuals experiencing homelessness after leaving an institutional setting (e.g., inpatient psychiatric hospital), providing a stable transition to permanent supportive housing.[3]

Pregnant and postpartum women have alarming rates of depression and anxiety. Over 15 percent experience anxiety or depression in the perinatal period, and 20 percent do during the postpartum period.[1] In the United States, the estimated prevalence of major depressive disorder in the postpartum period ranges from 9 percent among pregnant women to 37 percent at any point in the first year postpartum.[2] Perinatal mental health disorders are the most common comorbidity of pregnancy, and suicide is the leading cause of death among pregnant and postpartum women.[3] Yet, mental health disorders are the most underdiagnosed obstetric complication.[4]

The American College of Obstetricians and Gynecologists recommends postpartum follow-up care, including screening for depression and anxiety, for all postpartum women.[5] However, no major federal agency has done the same.

HRSA established the Women’s Preventive Services Guidelines in 2011 based on recommendations from a study by the Institute of Medicine that was commissioned by the Department of Health and Human Services. In 2016 and again in 2021, HRSA awarded the American College of Obstetricians and Gynecologists a cooperative agreement, the Women’s Preventive Services Initiative (WPSI), to convene clinicians, academic researchers, and consumer health professional organizations to develop recommendations for updated guidelines. Currently, the WPSI recommends screening for anxiety in adolescent and adult women, including pregnant and postpartum women but does not detail optimal screening intervals, and it does not recommend mental health screening for depression.[6] Additionally, the USPSTF recommends clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions but does not recommend screening for all pregnant and postpartum people.[7] Under the Affordable Care Act, USPSTF recommendations that receive an “A” or “B” must be covered without patient cost-sharing, which increases access to these services.

These guidelines should be updated to incorporate maternal health screeners for depression and suicidality in the perinatal and postpartum period.

Social media usage can be harmful for children depending on the time spent on platforms and the type of content children consume or are exposed. A cohort study of adolescents aged 12-15 found adolescents who spent 3 or more hours on social media daily were twice as likely to experience poor mental health outcomes such as anxiety or depression.[1] Social media can also perpetuate negative self-image issues and disordered eating, particularly among teen girls[2], while the majority of teens using social media are often exposed to hate content through social media.[3]

In May 2023, U.S. Surgeon General Vivek Murthy released an Advisory on Social Media and Youth Mental Health, noting the vulnerability of young people to social media harms and calling for action on the need to better research and understand the full impact of social media use on young people, the importance of maximizing benefits and minimizing harm of social media, and the need to create healthy, online environments for children.[4] Congress should act to protect children and youth on social media platforms by passing federal legislation that has the following privacy components:

Age verification:

• Requirement that social media platforms institute stricter age verification controls
• Ban children under 13 from engaging with content/users
• Mandate secure digital identification credentials

Increased safeguards for minors:

• Set default settings at the privacy settings
• Social media platforms should provide minors with tools to limit communication with other users, prevent public access of personal data, limit features that encourage prolonged use of platform, control personalized recommendation systems, and restrict geolocation sharing for minors

Transparency measures:

• Social media platforms should regularly release reports on how data can harm minors

Content controls:

• Ban content that encourages eating disorders, is linked to purchasing of controlled substances or firearms, gives information about how to harm oneself or others, commit suicide, or other harms
• Ban advertising of illegal products, moving beyond the previous standard that social media platforms use a “shall not facilitate” standard
• Social media platforms should provide information to users that allows them to control the content they see

Reporting mechanisms:

• Platforms should make clear reporting mechanisms

Data collection:

• Prohibit collection of personal information of teens 13-16 without consent

Additionally, the Assistant Secretary of Commerce for Communications and Information should create a program for researchers to access data from platforms for research on harms, the Director of the National Institute of Standards and Technology should conduct a study on methods to verify age of platform users, and the Federal Trade Commission (FTC) should establish a Youth Privacy and Marketing Division within FTC to address privacy of and marketing directed toward children and teens and provide guidance on market research/data.

Congress should address many of these issues by passing the Children’s Online Privacy and Protection Act (COPPA)[5], the Kids Online Safety Act (KOSA)[6], and Protecting Kids on Social Media Act.[7]

The postpartum period is a critical time for maternal mental and physical health. Extending Medicaid coverage can ensure that mothers have access to health care services during this period. The postpartum period is a time when women are at increased risk of developing health complications such as postpartum depression, psychosis, hypertension, infections, and cardiomyopathy.

Medicaid covers more than 40 percent of all births. Federal law requires states to provide pregnancy-related Medicaid coverage for up to 60 days after delivery for pregnant people with incomes up to 138 percent of the federal poverty level. Research demonstrates that expanding postpartum coverage beyond 60 days has many benefits for the mother and her baby. One study found that women who gave birth used twice as many postpartum services and three times the number of mental health and substance use services when they had coverage in the postpartum period.[1] The Department of Health and Human Services estimates that about 720,000 people annually would receive Medicaid postpartum coverage if states were to expand postpartum coverage to one year.[2]

The American Rescue Plan Act gave states the option to extend Medicaid postpartum coverage to 12 months using temporary state plan amendments, sunsetting after five years.[3] The Consolidated Appropriations Act made the state option to extend the postpartum coverage period for 12 months permanent.[4] As of July 2023, 46 states had either expanded Medicaid coverage for up to 12 months postpartum or were in the process of doing so.[5]

In addition to encouraging states to expand postpartum coverage, Congress should require states to extend the postpartum coverage period for 12 months, rather than making it optional as it is under current law.

Postpartum psychosis is perhaps the least understood of perinatal psychiatric disorders. It affects 1-2 per 1,000 women and constitutes a true psychiatric emergency that requires hospitalization and intensive treatment.[1] Postpartum psychosis is underdiagnosed and underreported by primary care providers, obstetricians, and psychiatrists, because, like many perinatal psychiatric conditions, there is no standard screening procedure in place during the prenatal and postnatal periods. The Edinburgh postnatal depression scale and the Mood Disorder Questionnaire have been found to be effective screening tools to identify signs of depression and mania in populations at risk.[2] However, insufficient research on postpartum depression and the lack of treatment guidelines mean far too many women cannot access needed care.[3] To address these barriers, the National Institute of Mental Health should prioritize and fund research relating to postpartum psychosis, and SAMHSA should convene the relevant clinical specialty association to urge them to create treatment guidelines.