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

Tragically, 90 percent of suicide attempts with guns are fatal, whereas 4 percent of suicide attempts not made with firearms end in death. Many individuals who die by gun suicide act impulsively and could have been saved by a waiting period for gun purchases.[1][2] A waiting period requires gun buyers to wait a certain amount of time before taking possession of a firearm they have purchased. The waiting period allows time for a background check, a cooling-off period, and an intervention or counseling for individuals who may be in distress.[2]

Waiting periods have proven to reduce firearm suicides by creating a buffer of time that can save lives. They are also supported by most Americans, including gun owners. However, only 10 states and the District of Columbia have waiting periods for all or some types of firearms.[3] The federal government does not require a waiting period for gun purchases, except for cases where a background check is delayed for up to 3 days.[2] Requiring gun buyers to wait 7 to 10 days before accessing a gun they have purchased would provide sufficient time for background checks and cooling-off periods.

Young adults aged 18 to 25 have the highest rates of substance use disorders (SUDs), including alcohol use disorder, compared to other age groups.[2] Collegiate Recovery Programs (CRP) provide supportive environments within campus culture for college and university students in recovery from SUDs.[3] There are more than 150 CRPs on college and university campuses nationally.[3] However, the diversity of models and practices has not been well documented.[4] Identifying best practices, which include dedicated space, trained staff, programs supporting recovery, and peer support,[3] and providing support and technical assistance, should be a priority for the ONDCP, SAMHSA, and DOE to increase the number and capacity of CRPs.[1]

Each year, Head Start programs serve more than 1 million children ages birth to five and pregnant people through federally-funded grantee organizations.[2] The Office of Head Start provides guidance to grantees on using quality improvement funds to support Head Start teachers in addressing behavioral challenges and potential mental health conditions.[3] Previously proposed legislation sought funding and requirements for the Health and Human Services Secretary to identify, review, and implement effective, evidence-based interventions that improve children’s mental health in Head Start programs.[4][5][6] Congress should amend the Head Start Act to prioritize support for evidence-based, trauma-informed programs, age-appropriate interventions, and mental health screenings.[1]

The onset of a mental health or substance use disorder (MH/SUD) occurs before age 14 for one-third of individuals and before age 18 for nearly half.[2] One in five students experience a significant mental health issue during their school years, highlighting the importance of educators understanding mental health conditions.[3] A number of pieces of legislation have been introduced to address the integration of evidence-based, trauma-informed, and culturally competent social, emotional, and cognitive skills programs in elementary and secondary schools and to train and educator training in best practices in responding to the mental health and behavioral needs of students.[4][5][6] Congress should fund educator training and professional development on mental health conditions in students by amending the Elementary and Secondary Education Act.[1]

The DREAM Act, first introduced in 2021, would provide legal protections to undocumented immigrants who came to the United States as children, commonly referred to as “Dreamers”.[3] These individuals are at an increased risk for mental health issues as they face many stressors related to working status, societal exclusion, and fear of deportation.[4] In 2012, former President Obama issued an executive order authorizing the Deferred Action for Childhood Arrivals (DACA) program, which provides temporary protection from deportation and allows individuals to get a time-limited work permit.[5] Unfortunately, DACA recipients and the broader population of Dreamers continue to experience mental health needs, though the needs of the community are not fully known. And when individuals do seek mental health treatment, they end up not finding culturally competent providers who understand their situation.[6] The DREAM Act of 2023 would alleviate some of the stressors of Dreamers and DACA recipients, thereby also improving their mental health.[1][2]

Unfortunately, high turnover and low wages have led to long-term staffing shortages among the direct care workforce, which includes home health and personal care aids, as well as certified nursing assistants who assist older adults and individuals with disabilities and other chronic conditions, including mental health and substance use disorders (MH/SUDs).[1] The direct care workforce is essential to help individuals and their families provide needed care and supports. To strengthen the direct care workforce, investments are needed in pay and benefits, education and training, and career advancement opportunities. Legislation such as the Supporting Our Direct Care Workforce and Families Caregivers Act would be a significant step in the right direction to addressing these challenges.[2]

Congress should also work to cover family caregiver supports in Medicare to allow family members or friends to receive modest assistance to allow them to care for individuals, particularly those who might otherwise be at risk of entering restrictive and expensive institutional settings. The Medicare Payment Advisory Commission (MedPAC), a nonpartisan, independent agency that advises Congress, previously reported that individuals who received more frequent care from informal caregivers, including family and friends, had fewer high-cost incidents that Medicare needed to cover.[3] While Medicaid allows states to reimburse for family caregiving through a range of different mechanisms, various agencies within the Department of Health and Human Services (HHS) could help improve family caregiver supports across states. Specifically, a recent report from the National Academy for State Health Policy recommended that HHS agencies identify and disseminate information about states’ family caregiver strategies; collect data relating to family caregivers who assist Medicaid beneficiaries; promote innovative state strategies; and provide technical assistance to states.[4]