Alignment for Progress: A National Strategy for Mental Health and Substance Use Disorders
It’s time for a meaningful national conversation about mental health and substance use care. We must remove the barriers to equitable and available coverage for these conditions so people can get the help they need.
Welcome To The National Strategy
Want to understand more about the importance of building a National Strategy for Mental Health & Substance Use Disorders?
How Content Is Organized and How Best to Search/Sort the Recommendations
The National Strategy recommendations are organized by category, with impacted populations and topical areas providing additional nuance and the ability to narrow a search. We have also included the option to search recommendations by the relevant House and Senate committees of jurisdiction.
Recommendation Selection Methodologies and Criteria
After conducting a thorough review of the federal policy landscape, The Kennedy Forum team created this first-of-its-kind compilation of policy recommendations needed to transform our mental health and substance use systems. The recommendations have been sourced and vetted from numerous organizations, advocates, and experts across the country in order to capture a robust set of recommendations for lawmakers and federal agencies to act on.
All National Strategy Recommendations
These featured recommendations are highlighted based on their importance in beginning the national movement towards better care for everyone.
Develop culturally competent guidelines for providers
The Substance Abuse and Mental Health Services Administration (SAMHSA) should develop culturally competent guidelines for mental health and substance use service providers[1], particularly those serving predominantly underserved communities—particularly Black/African American; Hispanic/Latino; Asian American, Native Hawaiian, and Pacific Islander; American Indian and Alaska Native; lesbian, gay, bisexual, transgender, queer, and intersex(LGBTQI+) communities[2][3]—through inclusive and responsive community engagement.
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.
Topics
Hold licensing boards accountable for ADA violations
Using its authorities under the Americans with Disabilities Act (ADA), the Department of Justice (DOJ) should issue guidance regarding the collection of mental health and substance use history by state medical and other licensing boards. The Department should investigate any ADA violations regarding the inappropriate collection of this information from healthcare professionals.[1][2]
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.
Topics
Reimburse for MH/SUD screenings during annual exams
Congress should enact legislation requiring all providers to provide and all health plans to reimburse for evidence-based mental health and substance use disorder (MH/SUD) screening during annual well-child and adult physical exams. This should include an Adverse Childhood Experience (ACE) component in addition to Screening, Brief Intervention, and Referral to Treatment (SBIRT).[1][2]
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]
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Fund research on black youth mental health and suicide
Congress should appropriate additional funding to the National Institutes of Health (NIH) and the National Institute on Mental Health (NIMH) to fund additional research on Black youth mental health and suicide.[1]
According to a report from the Congressional Black Caucus, the suicide death rate among Black youth is increasing faster than any other racial/ethnic group.[1] From 2000 to 2020, Black youth ages 10-19 also experienced the largest increase in suicide rates, 78 percent. And in a research study among the youngest children — ages 5-12 — Black youth were approximately two times more likely to die by suicide than their White counterparts.[2]
Historically, a small amount of research funding has been committed by the NIH, and specifically the NIMH, to investigate Black youth mental health and suicide increases.[1] In response to the growing concern over Black youth suicide, in June 2020 the NIMH released a notice of special interest to encourage research focused on Black child and adolescent suicide.[3] The notice outlines a number of research areas that could receive funding, including: epidemiology, etiology, and trajectories; intervention and services research; preventive interventions; treatment interventions; and services interventions.[3] This was followed by a Funding Opportunity Announcment (FOA) released in March 2022 with the aim to advance translational research to better understand factors that confer risk and resilience for suicide among Black youth.[4]
Continued investment in this space is needed. Congressional appropriators should provide NIH/NIMH with the resources they need to continue to fund research on Black youth suicide. Research areas of focus should include, but not be limited to:
- Risk and protective factors for suicidal behaviors among Black youth;
- Mental health motivation, utilization, and engagement among Black youth with an emphasis on examining motivation for mental health treatment;
- Risk and protective factors, as well as mental health utilization and engagement, among Black LGBTQ+/SGL (same gender loving) youth;
- Practical, systemic, and cultural barriers to treatment; the effectiveness of depression screenings by professionals across healthcare professions and institutions for helping to identify Black youth at risk for suicide;
- The effect of social media usage on Black youth; and
- Evidence-based interventions relating to mental health and suicide risk; in particular, those that are age-appropriate and culturally and linguistically relevant for Black youth.[1]
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Keep families together
The Department of Health and Human Services (HHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration on Children Youth and Families (ACYF) should disseminate best practices for states regarding interventions and strategies to keep families together when it can be done safely (e.g., using a relative for kinship care).[1][2][3]
An estimated 2.7 million children live with kin caregivers.[3] Individuals who care for a child whose parent(s) cannot, who are related to the child by blood, marriage, or adoption, or who have “an emotionally significant relationship” with the child are considered relative, kin, or fictive kin foster family (“kin caregivers”).[4] Prioritizing placing children entering foster care with kin caregivers instead of non-relative foster families[5], when it can be done safely, is preferred because it is usually best for children to remain with family, which reduces trauma and placement disruptions.[6] The Department of Health and Human Services (HHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration on Children Youth and Families (ACYF) should provide additional and more proactive guidance on best practices and technical assistance.[1][2][3]
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Pass the Pride in Mental Health Act
Congress should pass the Pride in Mental Health Act, which would direct the Department of Health and Human Services (HHS) to survey the mental health of LGBTQ+ youth to better understand their mental health and incidences of child abuse and neglect.[1][2] The bill would also improve mental health support for LGBTQ+ youth by developing new resources, training for caregivers, and school bullying prevention guidelines.[1][2]
LGBTQ+ youth report challenges with bullying, feeling sad or hopeless, and experiencing other mental health and substance use disorders (MH/SUD) at a higher rate than their non-LGBTQ+ peers.[3] Many LGBTQ+ youths may have to navigate an environment that might not be inclusive, or accepting of their sexual orientation or gender identity (SOGI) - especially within their families. [4] Family rejection, neglect, and abuse can lead to MH/SUDs.[4] These challenges have resulted in LGBTQ+ youth being overrepresented in the child welfare system and increase the chances of LGBTQ+ youth encountering homelessness.[5] Congress should pass the Pride in Mental Health Act to address the unique mental health needs of this population, especially those deriving from incidences of child abuse and neglect.[1][2]