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

The Americans with Disabilities Act protects people with disabilities from discrimination in areas such as employment, state and local government activities, public transportation, commercial facilities, and telecommunication services.[3] Both employers (Title I) and state and local governments (Title II) are required to make reasonable accommodations to give people with disabilities an opportunity to take advantage of all available job opportunities, resources, and services.[3] It is critical for these protections to be interpreted and enforced to protect people with MH/SUD and maximize their access to employment opportunities.[2] Currently, an employee or applicant actively engaging in illegal drug use is not protected.[4] This increases stigma and discrimination against people with SUDs.[5] In addition, certain mental health conditions, such as anxiety and depression, can make it difficult for people with MH/SUDs to access disability or life insurance.[6] While the ADA includes essential protections for people with disabilities, steps must be taken to ensure individuals with MH/SUD are afforded the same protections as those with other medical conditions.[1][7]

The Equality Act is essential to combatting widespread discrimination against LGBTQ+ people, who lack consistent and comprehensive federal protections.[1][2] Approximately two-thirds of LGBTQ+ people have reported experiencing discrimination in their lives, and such discrimination can negatively impact their mental health, increasing their risk of depression, anxiety, and even suicidal thoughts and self-harm.[2]

Passing the Equality Act would help reduce discrimination, decreasing a significant risk factor for poor mental health. Research has shown that LGBTQ+ people who lived in states that allowed same-sex marriage (prior to it being legal nationwide) had lower rates of mood, anxiety, and substance use disorders than those who lived in states that did not allow same-sex marriage. The very existence of marriage equality – even if the sexual minority men were not partnered – reduced health care utilization and costs for mental and physical health.[3] Other research has found that marriage equality laws “shrank the mental health gap between sexual minorities and heterosexuals.”[4][5] Another study showed that lesbian, gay, and bisexual individuals living in states with comprehensive legal protections have higher self-rated health than those living in states without these protections.[6]

Currently, mortality data for both suicide and drug overdoses lack standardization and are significantly delayed, which limits our ability to respond to these public health crises. As recommended by the 2017 Commission on Combating Drug Addiction and the Opioid Crisis, the CDC should work with states to “develop and implement standardized rigorous drug testing procedures, forensic methods, and appropriate toxicology instrumentation in investigating drug-related deaths.”[1] The CDC should do the same for investigating possible suicides, particularly given the difficulty of distinguishing unintentional and intentional drug overdoses.[2]

To assist with standardization across jurisdictions, Congress should significantly increase funding for local medical examiners and tie federal funding to standardized processes and reporting to ensure the availability of near-real-time data reporting. Funding should also be tied to standardized policies that allow access to linkable mortality data for purposes in the public interest, such as surveillance, research, and clinical quality improvement. Federal funding is particularly urgent given the chronic underfunding of many state and local medical examiners’ offices.[3]

Amidst attacks on LGBTQ+ individuals by many state and local governments across the country,[1] President Biden signed an Executive Order on Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals on June 15, 2022.[2] The Executive Order directs federal agencies to take steps to protect LGBTQ+ individuals from unlawful discrimination and eliminate disparities that harm them and their families, including safeguarding health care access and suicide prevention programs and supporting LGBTQ+ children and families in the foster care system. The Executive Order is consistent with the Supreme Court’s decision in Bostock v. Clayton County (2020), which held that Title VII of the Civil Rights Act of 1964 prohibits discrimination on the basis of sexual orientation or gender identity in employment. It also builds on the previous Executive Order of January 20, 2021, which extended the Bostock ruling to other federal laws that prohibit sex discrimination.[3]

Approximately two-thirds of LGBTQ+ people have reported experiencing discrimination in their lives, which can negatively impact their mental health, increasing their risk of depression, anxiety, suicidal thoughts, and self-harm.[4] According to the National Survey on Drug Use and Health (NSDUH), LGBTQ+ adults are more likely to experience mental health and substance use disorders (MH/SUD) than heterosexual adults.[5] LGBTQ+ youth are also at a higher risk of harassment, abuse, homelessness, and suicide.[6] Research has shown that lesbian, gay, and bisexual individuals living in states with comprehensive legal protections have higher self-rated health than those in states without these protections. The federal government should use all tools at its disposal to protect LGBTQ+ individuals from these continued assaults.

Individuals with intellectual and developmental disabilities (IDD) are at an increased risk for developing other mental health or substance use disorders (MH/SUDs).[2] IDD usually develops or presents in early childhood, and early diagnosis and intervention can lead to better outcomes.[3] To aid in early diagnosis, in 1994, Zero to Three developed a guide known as the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3), which was most recently updated in 2021 (DC:0-5).[4] With over 42 million children receiving coverage from Medicaid and CHIP, a recent survey asked states if their policies required or recommended the use of DC:0-5 or DC:0-3R.[5] However, only seven states require the use of the diagnostic classification, and only eight states recommend its use.[5] The use of age-specific diagnostic systems should be required for payment and utilization review purposes to improve access to needed care.[1]

The United States has the highest maternal mortality rate of any high-income country.[4][5][6] Mental health and substance use disorders are one of the leading causes of pregnancy-related death,[6][7][8] and are the most common complications of pregnancy and childbirth, impacting 800,000 women annually.[9] Low-income, Black, and other marginalized families are disproportionately affected.[10][11] Significantly, Black women experience maternal death at a rate 2.5 times higher than white women.[11]

The bipartisan Moms Matter Act, one of the thirteen bills within the Black Maternal Health Momnibus Act,[4][12] would invest in programs supporting moms with maternal health conditions and substance use disorders and provide critical funding to grow and diversify the maternal mental and behavioral health workforce.[1][2][3] It would make critical investments in the social determinants of health, including housing, transportation, and nutrition, that contribute to high maternal mortality among Black women, Veterans, incarcerated people, Native Americans, and other people of color.