Strengthening Federal Mental Health and Substance Use Disorder Programs: Opportunities, Challenges, and Emerging Issues

Chairwoman Murray, Ranking Member Burr and members of the Committee, The Biden Administration is committed to addressing the unprecedented mental health and substance use disorder crisis that is affecting adults and children of all races in urban and rural communities across the United States. During the State of the Union, President Biden announced the strategy to address our national mental health crisis as part of his Unity Agenda.¹ The three pillars of the President’s mental health strategy are: (1) Strengthen System Capacity; (2) Connect Americans to Care; and (3) Support Americans by Creating Healthy Environments. A These three pillars are built on a foundation of research carried out by the National Institute of Mental Health (NIMH) the lead federal agency charged with setting and supporting the national agenda for mental health research. It is my privilege to represent NIMH before you today, and to discuss our ongoing collaborations with partner agencies to support the President’s strategy.

The NIMH is one of the 27 Institutes and Centers that make up the National Institutes of Health (NIH), the largest biomedical research agency in the world. The NIMH mission is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. The NIMH Strategic Plan for Research guides the Institute’s priorities for funding research, from basic neuroscience aimed at understanding how the brain produces behavior, to translational efforts to develop transformative treatments, to clinical studies testing novel approaches in community settings. Indeed, research has driven significant progress in several key areas of public health, providing hope that drives us forward.

This translational pathway from basic science to clinical application is well illustrated by considering one recent advance in the treatment of postpartum depression (PPD), a mental illness that impacts 1 in 9 mothers and can be life-threatening.² Until recently, there were no specific treatments for PPD. But thanks to NIMH-supported science, that is no longer the case. This pathway to treatment development started in the early 1990s, when scientists with NIMH and the National Institute of Neurological Disorders and Stroke discovered that naturally occurring brain chemicals called neurosteroids were important for reducing the adverse effects of stress in laboratory animals. Subsequent work funded by NIMH showed that levels of one of these chemicals, allopregnanolone, fluctuate through pregnancy and drop rapidly at the time of birth, suggesting that low levels of allopregnanolone might lead to PPD and that giving extra allopregnanolone to women might treat PPD. Subsequent clinical trials published in 2018 confirmed this hypothesis, finding that brexanolone, a synthetic version of the natural chemical, can rapidly reverse the symptoms of PPD. This decades-long scientific effort culminated in the spring of 2019 with Food and Drug Administration (FDA) approval of brexanolone as the first ever treatment specifically for PPD.³

We are proud of NIMH research, and its role in developing transformational new therapies like brexanolone. And NIMH’s role does not stop there; we also collaborate extensively with other federal agencies, including the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), the Centers for Medicare & Medicaid Services (CMS), and others, with the goal of achieving mental health equity by ensuring that effective treatments are accessible to the people who need them.

One such collaboration has transformed care for psychosis in the United States. Maximizing the likelihood of recovery for individuals with schizophrenia and other psychotic illnesses requires delivering the very best care as early as possible in the course of their illness. But just what “the very best care” meant was unclear as recently as a decade ago. In the late 2000s and early 2010s, NIMH supported an ambitious research program – the Recovery After an Initial Schizophrenia Episode (RAISE) initiative – that tested the efficacy of Coordinated Specialty Care for those experiencing their first episode of psychosis.⁴ This research showed that individuals receiving this set of wraparound services did significantly better than those who received treatment as usual, particularly when interventions were offered early on. Perhaps even more importantly, the RAISE study showed that these services can be effectively delivered in community settings and are cost-effective when compared to usual care. Based on these findings, our colleagues at SAMHSA have used the Mental Health Block Grant program to fund First Episode Psychosis clinics around the country that offer Coordinated Specialty Care. Now over 350 such clinics are providing cutting-edge evidence-based care to thousands of Americans each year. In other interagency collaborations related to the treatment of early psychosis, NIMH has partnered with SAMHSA in their efforts to establish community treatment programs for those at clinical high risk for psychosis, partnered with HRSA to implement psychosis screening in primary care settings, and assisted the Department of Veterans Affairs (VA) in assuring high-quality services for Veterans with early psychosis.

Similarly, in the area of suicide prevention, NIMH is collaborating in science-to-service and service-to-science cycles of learning healthcare. NIMH research has shown that the majority of those who have died by suicide were seen by their doctor or another healthcare provider in the weeks or months prior to their death. Accordingly, NIMH has worked with numerous partners to improve suicide prevention efforts in healthcare settings.⁵ For example, findings from NIMH research have been incorporated into the “Zero Suicide” model, a systematic framework and multilevel approach to implementing evidence-based practices; this framework is now supported by grants from SAMHSA, the Department of Defense, and the Indian Health Service.⁶ Initiated by the National Action Alliance for Suicide Prevention – a public-private partnership – the Zero Suicide model is based on systematic implementation and continuous improvement of suicide reduction efforts, resulting in fewer suicide events within healthcare systems.

NIMH research has yielded relevant, practice-ready tools that form the backbone of the Zero Suicide approach.⁷ For example, NIMH funded the Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) study, conducted in HRSA-supported pediatric emergency rooms, to demonstrate the efficacy of screening for suicide prevention in these settings. A similar study in adults showed that emergency room screening combined with brief interventions and follow-up contacts can reduce suicide attempts by 33 percent. NIMH research has also supported the development of computational methods to identify suicide risk using electronic health records, an approach that has already been implemented in the Army, Veterans Affairs clinics, and many healthcare systems around the United States.⁸ Finally, NIMH research has demonstrated the efficacy and cost-effectiveness of interventions that can reduce suicide risk once detected, including Cognitive and Dialectical behavioral therapies, safety planning, caring contacts, and treating underlying mental illnesses.

To ensure that these evidence-based approaches to identifying and reducing suicide risk in individuals are being utilized, NIMH is working with SAMHSA, HRSA, CMS, the Centers for Disease Control and Prevention and other public and private partners to promote the use of Zero Suicide and other suicide prevention approaches throughout the United States. And while it is too early to declare victory, we are gratified to see rates of death by suicide decline for two consecutive years since 2018, after two decades of inexorable increases.

These and other efforts to improve mental health services through evidence-based solutions have been confronted with another challenge; the Coronavirus Disease 2019 (COVID-19) pandemic. The impact of the pandemic on mental health in the United States has been significant. Research supported by NIMH and others has confirmed much of what we knew based on prior research on disasters and epidemics. Through the course of the pandemic, the rates at which individuals note symptoms of depression, anxiety, substance use, and suicidal thoughts have all gone up.⁹ The demand for mental health services has also increased, especially amongst children. And the effects on our youth, though still not fully quantified, are substantial. These impacts have not been felt equally across American communities, with Black, Latinx, and other underserved communities as well as care practitioners and others on the front lines bearing the brunt of both the physical and mental health impacts of COVID-19. Suicide rates among Black youth, for example, have been rising for the past 5 years, eclipsing rates among White youth for the first time ever.

Yet even during the pandemic, research has offered hopeful solutions. Prior NIMH research conducted over the past two decades has demonstrated that telemental health care can be as effective as in-person mental health care when delivered appropriately; this research supported the rapid switch to remote care delivery in early 2020. NIMH research during the pandemic has demonstrated that social supports, such as the provision of meals to families threatened by food insecurity, help build resilience to the mental health impacts of the pandemic and subsequent economic disruption. And perhaps the most optimistic finding is that despite the increased rates of mental illness symptoms and increased demand for mental health services, overall suicide rates in the United States continued to decline through the first year of the pandemic.¹⁰

• Of course, we must nonetheless strive to do better. NIMH continues to gather evidence and collaborate with federal agencies and other partners to widely disseminate evidence-based preventative and therapeutic interventions. Some additional examples include:
• Family Navigator Models, which provide assistance to youth and families to navigate healthcare and social service systems with the goal of improving outcomes and retaining more people in care;
• The Collaborative Care Model for integrated care, which uses a team-based approach to incorporate mental health care into primary care;
• Learning Healthcare Networks, which utilize clinical data to constantly improve and innovate in providing effective, high-quality care to all patients; and,
• School-based Mental Health programs, which provide behavior management skills training and other interventions to reduce symptoms of depression and other serious emotional disturbances.

One quick fact to underscore this last example: NIMH-sponsored research has shown that mental health care for school-aged children is more readily accessed and more effective when delivered through school-based programs, especially for Latinx and other children from underserved communities.¹¹

We are faced with numerous challenges to the mental health of Americans, including the lingering effects of the COVID-19 pandemic, the crisis in youth mental health, including the impacts of media and technology use, challenges in caring for individuals with serious mental illness, rising suicide rates among Black youth and other vulnerable populations, and the limited efficacy of many existing treatments for mental illnesses. In this context, research to develop novel, effective, and scalable preventive and therapeutic interventions is more urgent than ever. At the same time, recent advances – such as novel technologies that are revolutionizing the understanding of the human brain, discoveries in the genetics of mental illnesses, and the successful development of novel, rapid-acting interventions for depression – provide an unprecedented opportunity to capitalize on mental health research and make significant progress for the future. Meanwhile, NIMH continues to collaborate with our federal partners, including those joining us here today, to ensure that evidence-based solutions reach those in need now. In short, we know what works, and we stand ready to help.

Thank you for the opportunity to provide this testimony, and I would be pleased to answer any questions you might have.

References

1. https://www.nimh.nih.gov/about/strategic-planning-reports
2. https://www.nimh.nih.gov/about/director/messages/2019/a-bench-to-bedside-story-the-development-of-a-treatment-for-postpartum-depression
3. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-post-partum-depression 
4. https://www.nimh.nih.gov/health/topics/schizophrenia/raise
5. Gordon JA, Avenevoli A, Pearson JL. Suicide Prevention Research Priorities in Health Care. JAMA Psychiatry. 2020 Sep 1;77(9):885-886. doi: 10.1001/jamapsychiatry.2020.1042. PMID: 32432690.
6. Hogan MF, Grumet JG. Suicide Prevention: An Emerging Priority For Health Care. Health Aff (Millwood). 2016 Jun 1;35(6):1084-90. doi: 10.1377/hlthaff.2015.1672. PMID: 27269026.
7. https://www.nimh.nih.gov/archive/news/2016/nimh-funds-3-zero-suicide-grants
8. https://www.nimh.nih.gov/news/science-news/2018/predicting-suicide-attempts-and-suicide-deaths-using-electronic-health-records
9. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1 .
10. Curtin SC, Hedegaard H, Ahmad FB. Provisional numbers and rates of suicide by month and demographic characteristics: United States, 2020. Vital Statistics Rapid Release; no 16. Hyattsville, MD: National Center for Health Statistics. November 2021. DOI: https://dx.doi.org/10.15620/cdc:110369 .
11. Sanchez AL, Cornacchio D, Poznanski B, Golik AM, Chou T, Comer JS. The Effectiveness of School-Based Mental Health Services for Elementary-Aged Children: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry. 2018 Mar;57(3):153-165. doi: 10.1016/j.jaac.2017.11.022. Epub 2017 Dec 24. PMID: 29496124