In April 2023, the Substance Abuse and Mental Health Service Administration (SAMHSA) released its Draft Strategic Plan for 2023 to 2026 and requested public comments. The Policy Center for Maternal Mental Health (the “Policy Center”) submitted the following letter in response to each priority area, with a particular focus on integrating behavioral and physical healthcare and strengthening the behavioral health workforce.
Dear Assistant Secretary Delphin-Rittmon,
The Policy Center for Maternal Mental Health applauds SAMHSA for the development of its 2023-2026 Strategic Plan for 2023-2026, particularly for its focus on integrating behavioral and physical healthcare and strengthening the behavioral health workforce. Please see our response to each priority area below. We welcome ongoing conversations about the maternal population and look forward to working with you through the Task Force being formed through the TRIUMPH for New Moms Act.
Priority 1: Preventing Overdose
Goal 1. To prevent overdose deaths in America, SAMHSA will support efforts to transform systems and services that increase access to and utilization of harm reduction approaches and effective treatments.
Objective 1.1. Increase utilization of medications for opioid use disorder.
Objective 1.2. Increase uptake of evidence-based interventions
Objective 1.3. Achieve universal access to overdose prevention strategies and education competencies.
Goal 2. To reduce overdose risk, SAMHSA will support primary prevention and strengths-based recovery approaches that reduce barriers and create more opportunities to thrive.
Objective 2.1. Establish recovery-oriented systems of care as the framework for promoting individual, family, and community health.
Objective 2.2. Enhance protective factors in preventing or delaying initiation of substance use.
Objective 2.3. Expand resources for families and caregivers impacted by overdose.
Objective 2.4. Strengthen factors to improve health, home, purpose, and community to address social determinants of health.
Priority 1, Our Response:
Maternal Substance Use Disorder (SUD) is a growing and very concerning problem, and we urge you to prioritize this population, given two lives are involved (and often more when a mother has more than one infant/child).
We are particularly concerned about the rising rates of alcohol addiction in young women and urge SAMHSA to work with the Office of Women’s Health and non-profit partners like the American College of Obstetrics and Gynecology and the states to educate the public and providers about these very concerning trends. Through the integration and whole-person care work with providers, it is also critically important for SAMHSA to promote the implementation of the HHS plans of safe care (POSC) framework for keeping mothers with Substance Use Disorder and their babies safely together.
Finally, according to the CDC, maternal overdose and suicide combined are the leading underlying cause of pregnancy-related death in the U.S. SAMHSA’s prioritization of this population is critical to America’s future.
Priority 2: Enhancing Access to Suicide Prevention and Crisis Care
Goal 1. To save lives and improve well-being, SAMHSA will lead public health efforts to reduce suicidal ideation and behavior.
Objective 1.1. Improve access to suicide prevention services
Objective 1.2. Improve the quality and effectiveness of suicide prevention services
Goal 2. To deliver crisis care across all communities, SAMHSA will improve the quality and accessibility of the crisis care system.
Objective 2.1. Improve the experience for people in crisis and for crisis care providers.
Objective 2.2. Improve allocation of resources across the crisis care ecosystem.
Priority 2, Our Response:
We urge SAMHSA to address suicide prevention not only in PCP settings but also in Obstetric settings (Ob/Gyn and midwife practices). SAMHSA could also look at coordinating with developers of medical/nursing school curricula developers and board testing organizations.
We applaud SAMHSA’s Zero Suicide Grant Program, which supports the implementation of the Zero Suicide Intervention. We outlined the benefits of this program in our Maternal Suicide Issue Brief and are promoting this model as well. We also believe that SAMHSA should be coordinating with CMS, whose leadership could promote the adoption of such models in ER and Primary Care/Ob settings. Consider evaluating the prevalence, quality, and effectiveness of suicide prevention in general healthcare settings, including maternal health settings.
Because of the high rates of maternal suicide, we encourage SAMHSA to recommend screening for suicide risk when a person reports suicidal ideation in a depression screener. If a person answers yes to having had suicidal thoughts, then the Columbia-Suicide Severity Rating Scale (C-SSRS) and Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) screeners or the Ask Suicide-Screening Questions (ASQ) Tool should be used to assess for suicide risk. All of these are prominent evidence-based suicide screening and risk assessment tools that should be used in the perinatal and postpartum period by front-line providers like Ob/Gyns. It is important to note that screening for suicide risk is only one part of the process used to identify suicide risk. There should also be a process in place for further assessment and risk formulation. If a person is identified as being at risk for suicide, a clinical workflow needs to be followed that all staff is trained in that emphasizes reducing access to lethal means, developing a collaborative safety plan, initiating treatment that targets suicidal thoughts and behaviors directly, and providing caring contacts that include warm hand-offs to skilled providers. Providers are encouraged to look at Zero Suicide to learn more about effective suicide care.
The Policy Center recommends screening for the risk of suicide when a person reports thoughts of suicidal ideation through the completion of a depression screener. This “if this, then that” approach is both feasible in primary care and obstetric care settings and is critical to saving lives. Additionally, as noted above, obstetric providers (Ob/Gyns and Midwives) are front-line providers who need training and capacity-building support to identify and address suicide and suicide ideation with a line of sight to referral pathways.
We want to ensure that SAMHSA is aware of the following research on maternal suicide:
- Maternal suicide deaths are more common than maternal deaths caused by postpartum hemorrhage or hypertensive disorders
- Suicide accounts for up to 20% of maternal deaths that occur in the postpartum period
- Maternal suicide is most frequently completed between 6 to 12 months postpartum
- Depression during pregnancy greatly increases thoughts about suicide while pregnant
- Research shows that screening has reduced symptoms of depression and decreased the risk of suicide
The maternal population (pregnancy and up through at least one year postpartum) should be included among identified populations at risk for suicide, and solutions for supporting mothers and their babies as a dyad be promoted and further developed, including the development of in and outpatient hospital and residential treatment programs.
Work to ensure that the crisis care ecosystem is trained and equipped to address suicide risk and presentation across all specialty populations, including the maternal population, which can present additional barriers to care, such as child caretaking and the risk of having children taken away. We further support funding of community-based solutions, including training these providers in how to bill Medicaid and Commercial insurance to ensure the sustainability of programs because such programs already provide mental health benefits.
Priority 3: Promoting Resilience and Emotional Health for Children, Youth, and Families
Goal 1. To ensure that all children, youth, and families have opportunities to thrive, SAMHSA will increase access to a comprehensive array of equity-driven behavioral health programs by increasing program integration and expanding pediatric behavioral health capacity.
Objective 1.1. Strengthen the nation’s youth behavioral health system by integrating behavioral health care across youth-serving systems, including child welfare and juvenile justice, with a particular emphasis on education and pediatric primary care.
Objective 1.2. Ensure that plans to develop the crisis continuum, in conjunction with the transition to the 988 Suicide & Crisis Lifeline, incorporates a specialized focus for children, youth, and their families.
Objective 1.3. Work collaboratively with other federal agencies and external stakeholders to develop strategies to increase capacity to deliver behavioral health services for children, youth, and their families.
Goal 2. To meet the specific needs of children, youth, and their families, SAMHSA will support the dissemination and implementation of evidence-based and culturally appropriate services.
Objective 2.1. Reduce health disparities and ensure the effectiveness of SAMHSA programs by establishing an equity-informed approach to data, evaluation, technical assistance, and service delivery that is specific to young people and their families.
Objective 2.2. Promote and coordinate technical assistance for youth behavioral health that provides guidance and expertise to professionals, organizations, and the public. Objective 2.3. Increase the inclusion of young people and family members with lived and living experience in the development, implementation, and evaluation of programs and services.
Objective 2.4. Guide the optimal use of technology to support the behavioral health of children, youth, and families.
Priority 3, Our Response:
Through this work supporting children’s mental health, we urge SAMHSA to remember that babies and children don’t go to the doctor alone, and these opportunities could be used to identify and support parents with their own mental health screening, intervention, and treatment.
Priority 4: Integrating Behavioral and Physical Health Care
Goal 1. To promote whole-person care and improve health outcomes, SAMHSA will advance the bi-directional integration of healthcare services across systems for people with behavioral health conditions.
Objective 1.1. Increase resources and service capacity through grants, educational materials, and technical assistance for mental health and substance use disorder education, screening, prevention, treatment, and recovery in physical health care settings.
Objective 1.2. Increase resources and service capacity through grants, educational materials, and technical assistance for physical health condition education, screening, prevention, treatment, and recovery in behavioral health care settings.
Objective 1.3. Increase availability and improve uptake of training, education, and technical assistance on evidence-based, trauma-informed, integrated whole-person care.
Priority 4, Our Response:
We strongly urge SAMHSA to consider using this funding to expand primary care providers’ and obstetric providers’ (Ob/Gyns and Midwife) capacity to screen and effectively treat depression and anxiety disorders by creating a “988 for Providers.” More specifically, creating a national consultation line for primary care providers to obtain real-time support from a psychiatrist to discuss a patient’s mental health with behavioral health professionals, including psychiatrists. Research shows PCPs are de facto mental health care providers and are treating depression but are not treating depression according to clinical guidelines, resulting in inefficient and often ineffective mental health treatment. A consultation program could address this. Such a service exists in many states for pediatricians. Still, it is a fundamental gap for PCPs who are being called on to provide mental health screening, preliminary diagnosis, and treatment plan development for depression and anxiety. This service could be modeled after the Health Resource and Services Administration (HRSA) – AIDs, National Clinical Consultation Center.
It could be valuable for those women and other birthing people with Severe Mental Illness who are receiving behavioral health services to be provided with pregnancy screening and referral to obstetrics when pregnancy is confirmed.
We are pleased that SAMHSA is using its authority to support whole-person care/integration of behavioral health into primary care, not just focusing on public mental health and SUD services. We also encourage SAMHSA to coordinate with CMS on efforts to integrate care for Medicaid and dual eligibles.
Priority 5: Strengthening the Behavioral Health Workforce
Goal 1. To meet the behavioral health needs of the nation, SAMHSA will support the active recruitment, training, and retention of diverse, qualified individuals into the behavioral health workforce.
Objective 1.1. Expand the number of Minority Fellowship Program fellows and enhance the reach of the Historically Black Colleges and Universities Center for Excellence.
Objective 1.2. Develop new pipeline programs by engaging high school, community college, and four-year university students.
Objective 1.3. Expand the availability of paraprofessionals, particularly peer support providers.
Objective 1.4. Increase the supply and capacity of the behavioral health workforce to provide new, innovative, and evidence-based treatment in community-based primary care settings.
Goal 2. To improve the quality of behavioral health care, SAMHSA will promote and support professional development initiatives to improve the competencies of service providers.
Objective 2.1. Increase the use of equity-oriented and trauma-informed approaches in SAMHSA’s training and technical assistance efforts for providers of behavioral health services.
Objective 2.2. Improve training and supports for providers who work with young people with or at risk for behavioral health conditions.
Objective 2.3. Increase awareness and utilization of practitioners’ education and training opportunities.
Objective 2.4. Promote evidence-based professional development to improve behavioral health providers’ competencies in line with the National Behavioral Health Quality Framework.
Goal 3. To increase the accessibility of behavioral health providers in all communities, SAMHSA will reduce barriers to the continuum of high-quality services.
Objective 3.1. Increase investments to reduce disparities in access to specialized behavioral health care.
Objective 3.2. Increase funding opportunity announcements that allow resources to be used to expand virtual care.
Objective 3.3. Decrease restrictions on credentialed practitioners working across state lines, particularly for under-resourced populations.
Priority 5, Our Response:
As outlined in the Moms Matter Act, it is vital to provide funding to diversify the maternal mental health and substance use disorder workforce (i.e., increase the number of therapists of color, certified peer support specialists, and more) and expand access to culturally competent care. These investments could take the form of grants to establish schools or programs to provide education and training for individuals or expand the capacity of existing schools or programs, including scholarships for students. Investing in community-based programs to support those who are expecting and in the postpartum period, such as:
- Group prenatal and postpartum care models;
- Collaborative maternity care models;
- Initiatives addressing stigma and raising awareness regarding maternal mental and behavioral health conditions;
- Programs at freestanding birth centers; and
- Suicide prevention programs
These investments would take the form of grants to eligible entities and prioritize those with a focus on racial and ethnic minority groups.
Additionally, SAMHSA has the opportunity to grow the mental health workforce by providing Technical Assistance to potential employers of lay mental health professionals such as Community Health Workers (CHWs) and Certified Peer Support Specialists (CPSSs). These professionals are well-established and recognized by the Centers for Medicaid and Medicare Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA). State-sanctioned training and certification exist in all 50 states for CPSSs and are growing for CHWs, including Texas and California. However, a substantive and foundational barrier exists: potential employers like health systems and behavioral health clinics are unsure where to find these trained professionals and are unfamiliar with supervisory requirements and billing protocol. A National Technical Assistance Center for the Employment of Lay Professional Workforce, and grants to state public health departments to raise awareness of such a center, could change the trajectory and support the implementation of lay professions into the U.S. health system. Such a program could be housed under HRSA or SAMHSA, though it’s important to note CHWs may provide a range of health care service support, not exclusively mental health services.
We urge SAMHSA to incorporate mental health peer support resources in its TA strategy on an urgent basis. Additionally, we hope SAMHSA provides clarity through its website and other communications about the TA services that are available and those that have yet to be created. The SAMHSA website does not provide clear guidance regarding mental health peer support TA to:
- Individuals interested in paid careers as mental health peer support specialists
- States with resources are seeking to expand the mental health workforce through certified peer support specialists,
- Potential employers interested in hiring and billing for these services,
- School districts with an interest in offering youth peer support services.
When such assistance has been requested from the National Technical Assistance Centers (TACs), they have been unsure how to support these inquiries and are unclear whether SAMHSA is aware of these gaps.
Further, the Peer Recovery Center of Excellence, the CoE with the greatest visibility, only provides peer support services and resources for substance use disorder (SUD) treatment. However, this needs to be clarified in the name or website. While there are TA resources available for mental health peer support through the National Consumer and Consumer Supporter Technical Assistance Centers (CONSTACs), the Mental Health Technology Transfer Center Network (MMHTTC), and the National Family Support Technical Assistance Center (NFSTAC), these resources are not clearly outlined on the website. By increasing communication and coordination on these available resources and by expanding the work of regional centers nationally, SAMHSA can improve awareness and utilization of technical assistance centers, ultimately contributing to the growth and broader adoption of life-saving services across the nation.
We agree increasing equity-oriented and trauma-informed approaches must be of the highest priority. Black and Indigenous populations face higher rates of Maternal Mental Health disorders as well as negative birth outcomes, which can be traumatic in nature. Additionally, those with prior traumas, including adverse childhood experiences (ACEs), face a higher risk of maternal mental health disorders, and untreated maternal mental health disorders have been called a child’s “first ACE.”
SAMHSA should consider working through professional associations, like the American College of Obstetrics and Gynecology, for example, to deploy these resources.
We encourage SAMHSA to address the need to expand residency training programs for psychiatrists and additional training programs for mental health nurse practitioners and to promote the inclusion of training in maternal mental health in medical school and master’s programs.
We are grateful for the opportunity to provide feedback on SAMHSA’s strategic plan and look forward to future collaboration opportunities.
Sincerely,
Joy Burkhard, MBA
Executive Director
[email protected]
Sarah Johanek, MPH
Policy Project Manager
[email protected]
