Transcripts For CSPAN2 Hearing On Mental Health Substance Use Disorders 20240708

Good morning. The Senate Health education labor and Pensions Committee will please come to order. Todayerer holding a hearing on our nations growing Mental Health and Substance Use disorder crisis. I will have an Opening Statement following by senator murkowski. Then we will introduce our witnesses. I believe Ranking Member will join us a little later as well. After the witnesses give their testimony, senators will each is have five minute farce for a round of questions. While we werent able to have it open to the public, live video is available on our Committee Website and if you are in need of accommodations, you can reach out to the committee or office of congressional accessibility services. We continue to see a high number of new covid cases, so we are having this hearing in a larger hearing room where we can be socially distanced limiting the number of people who are in the hearing room, experience depression, anxiety and other Mental Health disorders. Drug overdoses were on the rise, and our Health Workforce was stretched far too thin. Mental Health Issues were responsible for 56 million Doctor Office visits and 5 emergency room visits. In 2019, suicide was the second leading cause of death among adolescents. From 1999 to 2019, the rate of Overdose Deaths more than tripled and then covid19 hit and made things worse. Our nation lost over 100,000 people to it drug overdoses in a single year. Overdose deaths, especially deaths involving fentanyl, skyrocketed in my home state during the pandemic. Nationwide, we are also seeing a concerning rise in methamphetamine and cocaine use as well. Across the country, people are stressed and this pandemic has been especially traumatic for children. Our schools, teachers and education leaders are seeing this every day. Our educators are on the front lines trying to help so many students experiencing Mental Health challenges often without the support of trained Mental Health professionals. We have seen sharp increases in kids visits to the emergency room for Mental Health crises, thoughts of suicide and suicide attempts, especially among girls. As of last december, over 167,000 children have had their world shattered after losing a parent or caregiver to covid19, some have even lost both parents. We know marginalized students are facing the worst of these challenges deepening inequities they already face. We know educators and caregivers are facing their own Mental Health challenges from the strain of this pandemic as well. We need to continue helping our students and educators and ensuring schools have the support, training and resources they need. But right now, our Mental Health workforce is stretched too thin to meet the needs. If we just keep stretching without taking action, something is going to break. For example, nearly half of psychologists reported feeling burnt out last year. We arent even close to providing Mental Health care to everyone who needs it. 130 million americans live in areas with less than one Mental Health care provider per thousand people. In my home state of washington, our Mental Health Care Workforce is only able to meet 17 of our states needs. Meanwhile, nationwide, less than in 1 in 10 people who need treatment for Substance Abuse actually get it. These hardships are not felt equally. The highest increase in opioid deaths has been among black more thanes. Rates of suicide are highest among american indian. And pop with Developmental Disabilities already almost five tombs more likely to have Mental Health needs have had their lives up ended. While some communities may face greater Behavioral Health challenges, this crisis affects all of us. Even if we arent personally struggling with Mental Health or sub stoons use, we have friends and family who is are, whether we realize it or not. We all rely on First Responders, Health Care Providers, teachers and other front line professionals who are facing burnt out and trauma. We all have a stake in making sure people can get the help they need. Thats why democrats passed the American Rescue plan to provide resources for schools to hire counsellors and psychologists, communitybased Behavioral Health providers, programs to treat Mental Health, suicide, burnt out and Substance Use and more. But we are not done. Healing the scars of this pandemic wont be quick or easy. This will take years. And we must act accordingly. Its time to build on this committees bipartisan history of expanding access to Mental Health services and responding to drug Overdose Deaths like we did in 2016 and 2018. In my state, i have seen how communities can benefit from some of the critical programs this committee has worked on, inen colluding programs that the Substance Abuse is and Mental Health Services Administration. For example, in clark county, which saw fentanyl deaths trip until 2020, lifeline connections is using a grant to better prepare teachers and school personnel, Law Enforcement, First Responders and caregivers to respond to Mental Health crises and refer those in need to appropriate treatment. Meanwhile, in king county, federal support allowed to provide Mental Health services for over 150 adults experiencing homelessness. And the tribes and bands of the nation are using Grant Funding to fight the high rate of suicide in their community by update daiting their Health Records and Mental Health procedures, hiring more therapists and expanding tell health services, which has been critical to reach people during the pandemic. If were going to respond to the behavioral Health Issues this pandemic has made worse, its clear we have to build on these efforts. That will take legislative action. So i look forward to hearing from our witnesses about how we can do that and working with senator burr and everyone on this committee on a bipartisan effort to reauthorize, improve, and expand critical federal programs that address Mental Health and Substance Use challenges. I hope every member of this committee and the senate can Work Together to bring their priorities forward to us to include. My goal is to work with Ranking Member burr to fold these priorities together into a larger package that makes progress on many of the issues that were going to hear about today. Like suicide screening and prevention, youth Mental Health, the Opioid Crisis and breaking down barriers in access to hen tall health. Finally, i want to acknowledge that disorders do not exist in a vacuum. In addition to the pandemic, there are a lot of issues people are worried about right now from gun violence to Climate Change to systemic racism to just making ends meet. As we work to do more to help people struggling with depression, anxiety and stress, we also need to look for ways to solve the problems that are making things so hard for so many people in the first place. I hope to continue to work with my colleagues on these root causes as well. Id like to introduce two letters for the record. One from the American Academy of pediatric, the American Academy of child and adolescent psychiatry and the association with recommendations for addressing the National Emergency and childhood adolescent Mental Health and others for the American Federation of state employees highlighting the importance of supporting the behavioral Health Workforce. So ordered. With that, i will turn it over to senator murkowski for her opening remarks. Madame chairman, thank you for convening the hearing. I appreciate that. I want to thank senator burr for asking me to substitute in as Ranking Member today on this incredibly, incredibly important and certainly timely conversation as we talk about Mental Health and Substance Abuse disorders. You have outlined well i think the statistics, the challenges that were seeing. We knew, we have known for years now that Mental Health and Substance Abuse disorders have really been at crisis levels in many parts of the country. Certainly in my state of alaska, and we have seen those challenges and those issues only further compounded by this pandemic. Access across the country, access to Mental Health and Substance Use care remains severely limited. Exacerbating suicide and Substance Abuse rates. You have mentioned the statistics in your state, madame chairman, with regards to Mental Health providers and facilities in alaska more than 80 of our communities do not have sufficient Mental Health providers. Again, we are seeing this crisis only continue to elevate, and unfortunately, it knows no barrier on this spectrum. We are seeing more and more young kids. It used to be when we were talking about suicide statistics, we would look at that 25, 45 year age bracket. Now the alarm that were seeing is in 10, 11, 12yearolds, who are suffering. We have an obligation to hear and to respond. Alaska ranks second in the country for suicide deaths. We have seen a sharp increase in drug Overdose Deaths, just as we have seen across the country this year. Alaska has one of the highest rates of binge drinking. Suicide rates amongst members of our Armed Services have doubled. We have seen some very, very Disturbing Trends of late, and as we have seen, our native people face shockingly disproportionate rates of Behavioral Health and Substance Use disorders and suicides. These are statistics that keep you up at night not just because they are numbers, but these are real people. These are our constituents. These are people in our neighborhoods, in our communities. They are people who are in pain. And as we will hear from the young woman who will be introduced in just a momt, a youth advocate from anchorage, alaska, she reminds us that these people that are not statistics, but these real people are looking to us 3 they are watching the leaders waiting for us to do something, and i think the message of hope needs to be that we are paying attention, that we are listening and we are working together to try to address some of the root causes of what we have seen. Just within this committee, we have seen some strong collaboration on efforts. I have been working with senator hosten on the mainstreaming Addiction Treatment act, which allows Health Care Providers to prescribe a drug that can truly save lives with the medicationassisted treatment. In addition to lifesaving treatment, we know that we have to invest in wrap around Recovery Services. I have visited programs in alaska that focus not just on preventing the Overdose Deaths, but also really building a community for alaskans in recovery because that has to be the follow on. We have worked on efforts to reduce fetal alcohol syndrome disorders to address the Mental Health needs of senator smith and i are leading the Workforce Shortage loan repayment act to bolster our supply of providers, but also the tel Mental Health improvement a act to ensure that insurance covers these critical services. Senator king and senator kelly and i are working on the effective suicide screening and assess the in the Emergency Department act to provide resources for emergency room personnel to identify, assess, and treat individuals at risk of suicide. I think unfortunately, we know thats where far too many who are seeking help end up sitting in an emergency room where you dont necessarily have those that are trained to identify and assess. Later this week, im going to be introducing the guarding our Mental Health act to prevent cost guard members who seek help from being automatically processed for discharge. Again, we know we have to make headway on the stigma issues associated with Mental Health. And then with senator rosen, were going to be introducing the youth Mental Health and Suicide Prevention act to ensure that the grant can provide additional Mental Health programming to students. Madame chairman, we know around this senate here theres plenty that can divide us. I would like to think that Mental Health, Substance Use, these are areas we can find true bipartisan consensus and hopefully we can build a package that addresses these issues head on, and i commend the work that you have made along with rank ing member burr to do just that. Again, im looking forward to being able to troo the committee to a bright Young Alaskan and when it is appropriate i will do that. But thank you, i look forward to the testimony from all witnesses today. Thank you. We will now introduce todays witnesses. Senator burr has joined us, so i will turn it over to him to introduce our first witness. Madame chairwoman, thank you very much for holding this hearing and for the opportunity to introduce the witnesses to the committee. This doctor is the american psychology chief science a officer. He also serves as the john van setters distinguished professor of psychology and neuroscience at the university of North Carolina chapel hill. He began his academic career as an assistant professor and later director of Clinical Psychology at Yale University department of psychology. His research is focused on interpersonal relationships primarily amongsted a let isnts ask published more than 150 scientific articles and 9 books over the course of his career. He earned his masters degree from the university of miami, bachelors from emery. I thank you for being here today and for all your work on behalf of families across the nation ask in our great state of North Carolina. Thank you. Thank you, senator burr. Next we have dr. Durham. Shes the clinical professor of industry and pediatrics at Boston University school of medicine and Boston Medical Center. Shes a Board Certified physician with a background in pediatrics psychiatry and addiction medicine. Her roles have always been in marginalized community and a dedicated advocate for effect wit witable Mental Health treatment. Shes the director of training for Boston Medical Center transforming and expanding access to Mental Health in urban pediatrics or the team up initiative. So glad you could join us today. I look frd to your testimony. Our next witness is sara goldsby. She was confirmed by the senate in february of 2018 after serving as acting director. She has led the response to the Opioid Crisis and serves as ko chair of the emergency team. Meaning shes been on the front lines of the crisis we are talking a about today. Shes helped expand access across South Carolina. She also understands the importance of addressing social determinants of health and making sure people have access to care. She came before the committee to discuss Mental Health and Substance Use challenges related to the covid19 pandemic. Welcome back, i appreciate you joining us to share your expertise once again. Our next witness is jennifer lockman, the ceo of the Research Institute at center stone in nashville, tennessee. Dr. Lockman oversees all Program Evaluation activities at center stone. Her work focuses on developing and itsing new interventions to further Suicide Prevention care. Shes been a lead evaluator for Substance Use Services Administration grants focused on Suicide Prevention in youth and adults as well as in zero suicide health programs. Dr. Lockman, thank you for join ing us today. I look forward to hearing from you. And finally i will turn it over to senator murkowski to introduce our last witness. Thank you, madame chair. Im delighted to be able to introduce to the committee claire rainier. Claire is an articulate youth advocate. I think she has been able to effectively give voice to so many through story telling. This this capacity, she has encouraged others to speak out. I first came to recognize claire when her story was printed on the front page of the Anchorage Daily News some months back outlining what she had done as one individual who looked at what was happening around her as a young girl and the lack of availability of services, the questions that she had and really nowhere to turn but literally the internet. She had indicated in that article Mental Health was just never talked about. It was never talked about in the home. It was not talked a about at school. Even in Health Classes where you would expect to hear it, the discussion was about making sure that you ate the right foods, you got the right sleep, but we dont focus on Mental Health. So her advocacy has been one that is truly, truly impressive. Shes a recent graduate of west high school. Shes spending her gap year working with the National Alliance on Mental Illness there in anchorage. Shes going to be attending Middlebury College in vermont this fall. So thank you not only for being here today and sharing your story, but your advocacy and your voice on behalf of so many. Thank you, madame chairman. Thank you for joining us today to share your story. Its really important we hear voices like yours about what students are facing, so we appreciate it. With that, we will begin our witness testimony. Dr. , you may begin with your Opening Statement. Chir woman, Ranking Member burr, members of the committee, thank you for the opportunity to testify. Im dr. Print steen, chief science officer of the medical association. Epa is the largest professional organization representing psychology in the u. S. With over 130,000 psychologists. Theres been much discussion of a Mental Health crisis in the u. S. Today i want to talk briefly about what that crisis looks like. This is an issue that began well before the pandemic with millions of americans experiencing emotional and behavioral symptoms that we could have prevented. The u. S. Has faired more poorly thn most with a rate of suicide attempts this the United States higher than in any other wealthy nation on the planet. Theres simply not enough Mental Health providers and not enough investment in science to prevent Mental Illness. 1 of 7 americans with Mental Health is receiving treatment scientifically proven to work. The covid19 pandemic has made this much worse. In 2021 alone, cherns hospitals saw a 42 increase in selfinjury and suicide cases. School principals report their staff are overwhelmed with children experiencing apathy, hopelessness, anxiety and thoughts of death. To say this is a Mental Health crisis is not enough. This is an accumulation of decades of neglect, stigma and unequal treatment of Mental Health compared to physical health. Now we are at a turning point like we have not seen since world war ii when our country elected to make a serious investment in hen tall health by building the va system, investing in Mental Health workforce and forming the National Institute of hen tall health. That was over 70 years ago. The time has come again. Today we know physical and Mental Health is based on antiquated notions. Its time to create a Mental Health system that reflects the 21st century and we have no time to waste. Heres what you can do immediately to address this National Emergency. First, we need a diverse and robust Mental Health workforce. Today we have 5,000 psychology trainees who could serve a greater number of people if medicare were reimbursed for their work during residency just as currently occurs for medical residents. This makes good sense. Theres a an average of 700 hours of patient care experience, more than most medical residents, ask we can mobilize thousands of Health Care Workers quickly. Second, we have psychology science to deploy interventions. The Mental Health services for students act and reimbursement for psychologists to guide these partnerships can have multipier effects so each member of the workforce is building resilience with classrooms and schools. Third, we need to expand the integration of primary and Behavioral Health care because it works, put not with the onesize fits all approach. We need to support all evidencebased models and allow providers the flexibility to determine which model best suits their a patients needs. The 2022 Mental Health act enforcement report just submitted to Congress Indicates that our federal agencies are struggling. Congress must grant the department of labor the authority to assess civil monetary penalties for violations of the law or enforcement will be almost impossible. This will only get us part of the way. We need longterm strategies as well to fix this problem thats been growing for decades. Our country invests 15 billion annually to ensure that we have enough physical Health Care Providers with the appropriate specialties and spread throughout the country. Yet we invest less than 1 of that amount to build a Mental Health care work tors force. Congress must reauthorize to expand the psychology education and minority fellowship programs and enact the Mental Health professionals Workforce Shortage loan repayment act. Its also krit call that we expand our scientific investment in psychology science to better understand, develop treatments and build resilience before the next stressor occurs. A 1 billion increase to youth Mental Health would still be a small proportion of the allocation currently offered to study conditions that afflict far fewer youth than those currently suffering from psychology disorders. Thank you again for the opportunity to speak with you today. We stand ready to help you with any and all issues dealing with human behavior. We have the expertise to address your committees work and i look forward to answering your questions. Thank you. Dr. Durham . Distinguished members of the Senate Health committee for providing me with the opportunity to speak with you today. My name is dr. Durham, a pediatric psychiatrist at Boston Medical Center. In my over ten years at bmc and academic medical center, i have never seen our Mental Health Care Services stretched so far beyond their capacity as they are now. We have had 30 plus patient this is our Emergency Department, more than four times its capacity presenting with a much higher level of acuity, some waiting for evaluation and others waiting for placement in the psychiatric unit. The patients are predominantly low income with half our patients covered by med kid or the Health Insurance program. The highest percentage of any acute Care Hospital in massachusetts. 70 of patients identifies a black, 1 in 3 spook a listening waj other than english and over half live at or below the poverty level. Bmc is a particular expertise in connecting communities to health Ask Social Services and yet we still find it happens all too often that our patients with Mental Health and Substance Use disorders get stuck falling this and out of Treatment Systems and many cases ending up on the streets, only to present repeat dl to our Emergency Department. One of the issues that plays at the necessary supports for these patients are not in place including Affordable Housing and coordinated care integrated with the supportive chunt. The question is really how do we get people with Mental Health and Substance Use everything they need to survive and be healthy. Bmc is in the rl stages of implementing a Housing First approach and partnership with the city of boston to get People Living on the streets just steps from our hospital campus often times living with Mental Health and Substance Use issues house ed first. And then provide wrap around medical service asks social supports. Our hope is that this can work to break the vicious cycle for these folks that are a patients and can serve as a model for other municipalities to replicate. Its in the process of constructing an 82bed facility in nearby massachusetts to address the shortage of psychiatric beds and increase our ability to treat the Mental Health and Substance Abuse needs of our patients from across the reswron. The facility is expected to provide 56 psychiatric beds with the capacity to treat patients with cooccurring disorders and Stabilization Service beds. We estimate the project will involve 27 million startup cost, barrier that the government could help lower to expand in patient capacity. As a black Spanish Speaking psychiatrist, able to prescribe im aware the patients that we are failing to reach. The u. S. Has eclipsed 100,000 annual drug Overdose Deaths for the First Time Ever while nationally Overdose Deaths have increased in every major demographic group. Black men experienced the largest increases. Even in massachusetts where we have seen populationwide drug Overdose Deaths level, the death rates for black men stand out in stark contrast. Having increased 75 between 2019 and 2020. Communities of color are suffering from covid19 and they are. Netting at disprotorsion gnat rates, baring the brunt of two compounding Public Health crises. At the same time, black men have low rates of Substance Use treatment. At bmc, we launched the accelerator to eliminate the equity gap by datadriven and communitybased research to change the way we approach care for blacks. While we dont have all the answers, we know a one size fits all approach did you want work and that access. Reauthorizing funding to support states responding to Mental Health and the crisis and flexible ways is crucial. Thank you to the Senate Health committee for your commitment for coming together to sustain funding in these critical programs over time. Id like to end by providing a a glimpse into the reality of what our patients face every day. One of my recent shifts a man in it his late 20s came in seeking help for his Substance Use. In our short time together, he described his opioid use at 9 years of age. They were using, there was minimal supervision in the home. The patient that experienced years of Substance Use, death of many family members and unsuccessful relationships with limited supports. He has been in and out of treatment over the years as well, but our system designed to exacerbate issues and prevent recovery. We must work to transform our Mental Health care system into one that recognizes relapse as reality, coordinates care, destigmatizes Substance Use and one that sees the humanity in people with substance it use issues as that can enable them to recover and live healthy fulfilling lives. Thank you for your time and i look forward to the discussion. Thank you very much. Director goldsby . Good morning, chair, senator murkowski and minutes of the committee. I serve as director of South Carolinas department of alcohol and drug abuse services. I also serve as president of the National Association of state alcohol and drug abuse directors. Its a privilege to join you today. Id like to begin by thanking you for your work to pass the comprehensive addiction and recovery act and the cares a act and the support act. In addition, thank you for providing historic federal investments in programs housed within the Substance Abuse Services Administration, including the Substance Abuse prevention and treatment block grant. As you mentioned earlier, our country continues to experience the devastating kmkt of Substance Use disorders and the number of Overdose Deaths is simply staggering. In my home state of 1 00, Overdose Deaths have increased by 60 over the last five years. And more of those deaths occurred in the last two years with the increased use during covid19 and the incredibly potent fentanyl supply we have been inundated with. Onethird of individuals admitted to treatment in the addiction system cited heroine as their primary Substance Abuse. Yet we also know Substance Use disorders impact different states, counties and communities in different ways. In South Carolina, were seeing a rise in admissions to treatment disorders where 42 of people admitted to treatment recorded alcohol as they prior may problem theres no doubt the covid19 pandemic contributed to increases in problems related to Substance Use disorders, yet we have all worked to adjust. States and providers have developed innovative approaches to prevention, treatment and recovery programming. Federal agecies and congress have worked to provide important flexibilities through Program Guidance and communication. In addition, congress and the administration worked to provide critical funding for prevention, treatment and recovery along with lifesaving overdose medication. As i observed the work moving forward in the field, i continue to be inspired by the incredible kmimt commitment and resolve i see on a daily basis. Im particularly grateful for our front line providers even though they are exhausted, they are stretched thin and continue to serve, they continue to help and save lives. And they continue to help find a road for recovery for everyone they serve. And i offer a number of recommendations as we continue our Work Together. First, we asked that federal policy inensures as the lead federal Agency Service delivery. We believe it shub the Default Agency for all federal Substance Use programming. And we applaud the stapt secretary for Mental Health as a leader. Succeed, please work to ensure federal policy initiatives ask trillion funding for Substance Use disorders flows through state alcohol and drug agencies. Given our work to ensure quality and evidencebased services and to ensure effective planning, i want plemtation and accountability. Third, we hope for continued support of the sapt block grant. The flexibility afforded allows states to target resources where they are need more based on data and the conditions on the ground. Our country faces a giant workforce problem. Were struggling to find people to do the job and while we appreciate it, we need an all hands on deck it approach. We hope this committee will give its programs full Statutory Authority to help with our workforce challenges. Since this time, its been actively working with stakeholders to prepare for the launch. As we move forward, we ask that congress and others specifically elevate and specifically reference Substance Use disorders as a core focus. We believe this approach is needed given the many unique considerations that serve as delivery for Substance Abuse dords and crisis. Finally, we Hope Congress continues to work with stakeholders and the administration to maintain certain flexibilities. And im happy to reare view other recommendations with the committee as time permits. In the meantime, thank you for the opportunity to testify today. I look forward to questions you may have. Thank you. Dr. Lockman . Make sure your mic is on. Can you hear me now . No. Can we have a staff person . Or senator burr. Is this okay . Yes. Thank you for the help. I would like to thank the chair and Ranking Member burr and the committee for your commitment to the crisis our country is facing. Id like to thank the senator for his leadership for the state of indiana, which is one stiefts we are proud to serve in. Im honored to be here as the voice of anymy cloegs and most importantly on behalf of the people we serve. Its the naugss largest nonprofit Mental Health company it provides communitybased health care, sub stabs abuse treatment and intellectual and developmental services. At the Research Institute, we conduct research to prevent and cure Mental Illness and addiction. We work to translate data to meaningful tools and practices reducing the research to practice gap. We applaud this hearing today because unfortunately, due to suicide, overdose and drug and alcoholrelated disease are all too prevalent. It was the leading cause of death for adults and third leading kausz for youth. 40 and 50 of americans have been exposed to suicide during their lifetime. This means that at least half of us sitting in this room today are likely to have been personally affected by the loss of someone that we loved to suicide. For this reason, congress in partnership with the Services Administration created the National Strategy for Suicide Prevention, Emergency Response Suicide Prevention grants. The Health Care System is honored to share our experience and the outcomes from some of our grants we have received. We are now working to spread evidencebased practiced known to decrease suicide and using data to make them even better. For example, we have updated our Suicide Prevention pathway to ensure eneveryone in our Health Care System gets suicide screening, Risk Management and treatment. We have moved towards a new system that first asks more about upstream risk factors for suicide. And then also asked a about suicide directly. We anticipate this screening process helps identify and treat drivers of suicide risk earlier and with Better Outcomes. We have also piloted a Suicide Prevention Specialty Care clinic, the first known in the United States. We expect all of our clinicians to be able to identify and treat suicide rusk, however, its costly to keep all uptodaten treatments as fast as the science changes. And medicine we have seen people get Better Outcomes when a at high risk by seeing specialtists like cardiologists and oncologists we are creating a referral system so persons at the highest risk for suicide can also be seen by a specialist, someone trained in multiple troomts, the very best that science has to offer. Our grants have also provided a crisis followup program for youth and adults during care transitions, a highrisk period for suicide attempts. Our data sgt. Suggests this Program Helps individuals reestablish connectedness, reduce and successfully link to Outpatient Care 70 to 90 of the time. These services would be unbillable and impossible without the federal grants. Knowing this Program Works to save lives is especially timely given the july 2022 launch as the dialing code for the lifeline. As we look toward launching, we must also continue to evaluate strategies to ensure services are funded and available nationally. This is why we also support the Behavioral Health Crisis Services expansion act as a crucial component of financing a continuum. Another Grant Program thats been a lifeline is a Behavioral Health clinic and Grant Program. It allows consistent care for those with Mental Health or Substance Use conditions and a place to go in times of crisis. This model is helping to address some of the dire workforce challenges our field has faced even prior to the pandemic. We recommend continued investment in the program. Center stone is also pleased to be one of the only few comprehensive recovery grant resip yepts in the nation. We recommend continued investment in this promising program. Of all the thing its you might take away from my testimony today, please be sure to hear this. Federal funding works. Federal funding saves lives. Federal funding helps prevent suicide and substancerelated deaths, using Program Evaluation to make programs even better and helps individuals recover and contribute this their communities. In the words of one of our clients, quote, theres no way to define a future if you are thot there for it. Everyone is focused on making sure you stay there for it. Stay alive. Stay safe. Its been helpful for me to develop my own path. Its made a lot of difference. Its been one of the great joys of my life to windchill people dpo from a place of deep despair to rediscover their strengths and build a life they really want to live. Thank you and i look forward to your questions. Thank you very much. Mr. Rainier, well turn to you. Chairman murray, Ranking Member burr, senator murkowski and members of the committee. Thank you for having me be here to testify today. My name is claire rainier, and im from eagle river, alaska. In high school, i was a story teller and facilitator for Mental Health advocacy through story telling. This organization is a youthled group of students working to decrease stigma and increase access to Mental Health resources. Last year i worked as a program ask Outreach Coordinator for the alaska affiliate for the alliance on Mental Illness. Im here today to advocate for youth who have or currently are experiencing Mental Health conditions. Im advocating for myself, my peers, for alaskan youth, but also for youth across the nation to give them a voice. To be clear, the people who most need the services are least able to be here a advocating. Im representing the tip of the iceberg. A few years ago, i experienced a difficult and tark period of depression. But more than being difficult and dark, my experience was governed by confusion. I was selfharming and all i felt was uncertainty. I asked myself, do i need help . How should i know . I turned to google taking dozens of are you depressed quizzes. However, google is not a doctor and is in no position to diagnose a middle school girl or anyone. It left me more confused each night i wondered what was wrong and in hindsight, it is terrifying to know i was physically harming myself and still unsure if i needed support. What i uncovered online and on social media was horrifying. The photos, videos and stories were disit tushing, but it was even more disturbing to discover i was attracted to it and found myself going back to it. No one bullied me or denebraska glekted me. My life was perfect. Mental health was never discussed at home or school, beyond the take care of yourself, get sleep, eat well and exercise. So i kept telling myself everything was okay. Why should i feel sad . Why should i feel lost . Im so fortunate, how could i possibly feel this way. Ultimately, i didnt seek help because i didnt know if anything was wrong. Im more than an anecdote. When i tell a room people of people i was confused or that i turned to google for help, i see a chorus of nods. I need more than one hand to count the number of Close Friends who have experienced suicidal thoughts. And barriers to care do not discrimination. They infiltrate every home, regardless of ethnicity, class or geography. Compared to most, im privileged. Finding a community of peers let me know i was not alone. I was once again a able to be focused on school, sports, my family and friends. I learned how to maintain my wellness, and im proud to say i know where youre coming from and this pain can be temporary and to know it is true. The people who did not find support are not here. Many of them will never be able to tell us their story. So we have an obligation to these youth to make a difference. We need to support school counsellors, station social workers in schools, fund Wellness Programs at universities and introduce Mental Health curriculum into Health Classes where they belong. We must reflect on the way we separate academic success from mental well being. We need to make care more affordable, and that its covered by insurance. Culturall Health Care Workers and diversity among providers. We need to reduce stigma, promote early intervention, normalize Mental Health conversations early, and educate our youth, teachers and parents. Those of us who know suicide and Mental Illness are preventable are watching the leaders of this country and waiting for to you do something. And the ones who think suicide and suffering is inevitable, they need you. Vulnerability is contagious and powerful, so im here in the hopes that my story might inspire change both for all of us to work towards healthier communities, but also to inspire other young people who may be listening. If you are suffering, i urge you to speak up. Thank you. Thank you very much. I want to thank all of our witnesses, but ms. Rhyneer, thank you for your compelling personal story, your courage, and you are making a difference. We all appreciate it. With that, we are going to begin a round of fiveminute questions. I, again, ask my colleagues to keep track of the clock and stay within those five minutes. And i will begin with dr. Prinstein. You know, as we all know, the last two years have been incredibly difficult in so many ways, but especially on children and in youth. They have faced huge disruptions in their own lives. Theyve lost loved ones including their parents. Theyve missed out on valuable time with their friends and teachers, and its become so dire that some of our leading experts have declared a, quote, National Emergency when it comes to child and adolescent Mental Health. As a mother myself, a grandmother, and as a former preschoolteacher, im really worried about our kids right now, and we just heard very compelling story from one of them. I know parents from my home state of washington all the way from here to the capitol are really concerned about this. I think its really important to address the effects of trauma, Substance Use, grief, and other stressors on our kids. And i wanted to ask you today to talk with us about the best practices for identifying trauma and other stressors among our children. Thank you. We have a number of assessment tools that we can use to screen kids and to understand what their experiences may be or even before they experience the crisis. We need to be able to launch the tools and research how we can use technology to really make the most use of the kinds of passive screening or opportunities to intervene and offer Mental Health tips, anything that we can do. In particular, this is really important when we think about underserved and underrepresented youth. It is absolutely critical that we are discussing Mental Health in schools, that we are building into our curriculum social and emotional competence. We have the tools to build kids resilience. We just need the opportunity to be able to teach what we know to all of those teachers and counselors and administrators so we can help them to identify kids before they reach a moment of trauma. Thank you. Dr. Durham and dr. Gold by, i want to talk about inequality within our Health Care System. Its led to outcomes and resources and Behavioral Health is obviously no exception. When trying to get care, people of color often face systemic barriers and are less likely to complete treatment or even get appropriate services. Individuals with disabilities are five times more likely to have Mental Health needs, often cant find providers to get the care they need. Meanwhile, in our Rural Communities we face shortages and members of the Lgbtq Community are more likely to experience Mental Health and Substance Use disorders. We have to do everything we can to address those disparities. So, dr. Durham, i want to start with you. Your work is at a safety net hospital and you see parents experiencing patients experiencing Mental Health and Substance Use crisis. What barriers to care do your patients experience, and how do they impact Behavioral Health outcomes and access . Thank you, senator murray, for that question. You described a lot of things in your Opening Statement that are inequitable in Mental Health in general. I think largely what many of us as witnesses have said during our testimony so far is that theres a huge inequity in just the workforce issue. Having Mental Health providers that maybe dont want to work with people with Substance Use issues. Having folks that focus on Substance Use issues that dont want to work with the Mental Health aspect of the patient. That adds a complexity when people want to go for care that they have to go to many different providers to get the treatment that they need. We need to stop siloing health care in general and Mental Health care, this distinction that our physical health is separated from our Mental Health. So we see often that people get lost because they go from one provider to another trying to get the treatment they need and deserve, and they cant find one provider to do all of those things. The second thing i will say is just in general getting access to care is very hard for our patients. There are a lot of barriers when we start thinking about what Substance Use treatment programs only want to give medication versus thinking about other psycho therapeutic interventions, how people get into treatment is very different. Providers will say you need to go to the emergency room intoxicated to get a detox bed. If not, theyre not going to accept you. This is the reality of how patients get treatment in the system. Because of bed availability, because of the way reimbursement happens, because of the way insurers operate. And, last but not least, i do want to think about how do we think about Substance Use in general, the inequity in that. I think its probably the only disorder that we consider a crime. You can get stopped. You can get pulled over for simply using or possessing this, and we dont treat it like other Mental Health or physical Health Issues. I do believe it is a brain illness. Its chronic. Its relapsing and remitting, and it deserves full treatment like anybody with diabetes, hypertension or any other condition. Thank you. And i am out of time, so ms. Goldsby, i will come back to you if i can later on to ask you that question. I will turn it over to senator murkowski. Thank you, madam chairman. Claire, thank you. Thank you for your testimony. Very, very compelling. And thank you for your voice, your leadership in this very important area. I recall a visit i made out to rural alaska some years ago. It was a town hall meeting with native leaders and young people from a neighboring village had come to the town hall and asked to be recognized, and they raised the issue of suicide. None of the adults in the room wanted to talk about it. The young people one young man said, suicide is becoming normal within our village as far as the youth were concerned, which was shocking and troubling. But it was almost as if there was a generational disconnect, the kids wanted to speak about it, needed to speak about it. And the elders in the room were afraid. They were afraid, i believe, that if they spoke about it, it might be encouraged. You have been involved in Suicide Prevention, trainings in school, peer to peer. Share with me a little bit, if you will, and the committee not only the importance of increasing access to these trainings and the recommendations for how we can reach out to kids, because, again, it is younger it seems younger and younger children are feeling the sense of depression and despair and crisis and suicidal ideation. Its important how we speak to one another so that it is heard. Can you address how we can provide for more in the curriculum thats actually meaningful to kids, how we can provide for counselors who understand how to speak the language, because i fear that theres a disconnect there . Absolutely. Thank you. Yes, suicide is a huge issue in alaska and, actually, one thing alaska does the Youth Risk Behavior survey. And they show that the percentage of students attempting suicide has grown significantly in the past few years. So in 2019, 25 of all students in alaska schools seriously considered suicide and 20 of them attempted 20 of them attempted, and so thats onefifth of my classmates. But, like, how many parents do you think knew about it . Do you think onefifth of parents knew their students had seriously attempted suicide . So one thing that prevents students from talking about it is honestly the stigma that parents have, so they never even reach the point of asking for help because they diminish their experience, they dont believe anything is wrong. Theyre scared. They think their family will crack jokes and not take them seriously or expect their parents to blame themselves, afraid they will be seen as a broken or lost cause, any of those things. So reducing stigma in general, one of the things we can do, like in alaska what were trying to do, is pass a bill that would help bring mental Health Education into k12 schools. So by talking about Mental Health in schools, specifically in Health Classes, we begin conversations early and allow space for people to share. So Health Classes currently cover topics like nutrition and physical health, exercise, dental health, all these sorts of things, cancer prevention. And Mental Health deserves to be a topic in one of those classes. Its just as important. And guidelines for this kind of curriculum would be developed with local and statewide and National Agencies to make sure it was safe and age appropriate and, of course, we wouldnt be teaching the same thing to High Schoolers as Elementary School kids, but it would help you note the symptoms and recognize them and what to do about them and reach out for help. So thats one really important thing. Also, in terms of Suicide Prevention just like clubs like you are not alone club that does Suicide Prevention trainings in schools and goes around to classes and talks about it. Those are really important things, too. So all of those things working together. Thank you, claire. Madam chairman, im almost out of time, but i think every one of the witnesses in one way or another has talked about the need for workforce and whether it is school counselors, those that can work with the kids in programs, or whether it is all the way to the other end with a full Psychiatric Care that is available. And my hope is that we build out a package, a focus, on Mental Health. That we key in on the workforce issues. I think we recognize in all our states we are sorely, sorely lacking. Thank you very much. I look forward to working with you on that. Senator casey . Chair murray, thank you for the hearing. I want to thank you and senator murkowski and Ranking Member burr and, of course, our witnesses. I want to start with director goldsby with a question regarding plans of safe care this is an issue ive worked on for years to support both infants and families affected by Substance Use disorder. We know that infants and their parents need what, i think, most would refer to as nonpunitive services as well as treatment and support as parents navigate both recovery and parenting a young child. But despite longstanding federal law, plans of safe care remain very much underutilized. I appreciate the work of this committee and the legislation and authorization over time to address some of the issues that have contributed to these plans of safe care being underutilized. Too many families are slipping through the cracks, and in particular i appreciate the effort to establish a reporting mechanism when an instant needs a plan of safe care that is separate from the Child Welfare system. But, director goldsby, what steps can we take in congress, especially here in the senate, to help states and communities adopt Public Health driven approaches to Substance Use in both pregnancy and as well as to reach more families in need of support . Senator casey, im glad you asked. Thanks to the work of this committee and the work we have under way, we are currently engaged in some indepth Technical Assistance with my agency and our selfcarolinas we work handinhand to develop a plan to address your exact concern. Our plan is focusing on moving Intervention Services upstream, a more Public Health approach to support all pregnant individuals who might may or may not have a Substance Use issue but the screening, having that universal screening and referral to treatment for everyone early and often in pregnancy. Weve decided to call our plan of safe care a Family Wellness support plan because our aim will be to initiate that plan sooner and as soon as the mother is identified either with toxicology or the screening so that were offering a nonpunitive support of services to include Mental Health and Substance Use treatment and all the raparound services. For some who have severe diagnosis, this plan might include a referral to one of our family care centers, which is our residential treatment for women and children but the Substance Abuse grant, so that mothers can really stay engaged in services and supported through the delivery of their child and that way Health Care Providers know that theyre engaged, that theyre in treatment, and this will all lead to more likely results of family remaining unified at the time of delivery so that the mother and the children can continue on in that residential treatment or be discouraged home to communitybased services. But a lot of education has to be done among our Health Care Community for them to understand that, like we mentioned, Substance Use disorders is not a moral failing but is a health care issue, a disease state, and that people with Mental Health and Substance Use issues shouldnt be further stigmatized but assisted. Just note that all of this work, you know, is supported by our pregnant and parents, expert work assisted by grants. Director, thank you for your work. I appreciate your answer. I wanted to turn to dr. Prinstein. On page 16 of your testimony you note that implementation of integrated care where primary care and Behavioral Health care providers work as a team remains, unfortunately, limited. While there are a lot of models that integrate physical and Mental Health care, many physicians still dont have the ability to seamlessly connect patients to a Mental Health provider. You mentioned some of the barriers, whether its physical space or i. T. Issues or clinical staffing. What should we do in terms of our focus to help more primary care providers move towards integrated care, and how can telehealth grated care is an Excellent Way to go. Its very hard for people to find a health care provider, and a Mental Health care provider, and due to stigma sometimes even pursuing that in person is difficult. But walking into your Physicians Office is not attached to stigma. Three things to remember with integrated care. One, its a lot more than just sticking a Mental Health care provider into the office of a physician. This is really about the time and the funding thats required for cross training, so that way physicians and Mental Health care providers can speak each others language, share records, billing processes. Not the traditional onehour sessions with a Mental Health care provider. New billing processes are needed. Infrastructure costs are required to successfully integrate behavioral care to implement that, so it is important to incentivize officials to do so. A one size fits all approach will not work with integrated behavioral care. All approaches can be very effective and primary care providers need to be the folks to decide how best to set it up in a way that meets their needs, their patients and their community. Thank you, doctor. Thank you, chair murray. Thank you. Senator collins . Thank you, madam chair. Dr. Prinstein, i want to discuss with you the impact that the prolonged covid pandemic has had on our childrens Mental Health. I was struck by two recent columns in the New York Times written by david liamhart in which he makes the point very well. He writes, the pandemics disruptions have led to lost learning, social isolation, and widespread Mental Health problems for children. Many American Children are in crisis, and here is the important point. As a result of pandemic restrictions rather than the virus itself. We know, as senator murray has mentioned, that three medical groups representing pediatrics, child psychiatrists, and childrens hospitals have recently declared a National Emergency in child and adolescent Mental Health. And the New York Times columnist has concluded that remote schooling has failed and theres little evidence that shutting schools leads to fewer covid cases among children. Given that the pandemic has persisted for two years, which is a good portion of many childrens lives, what should we be doing as policymakers to balance Pandemic Response policies with the serious concerns that many parents have expressed to me about their childrens the impact on their childrens Mental Health, the social isolation, the remote learning, the restricted activities that they are seeing directly are harming their childrens social and Mental Development . Thank you for raising that, senator collins. Apa joined with aha and aap in declaring that National Emergency, and we agree the science is telling us kids are experiencing Mental Health difficulties for a whole host of reasons. One is, of course, the major stressor that has occurred in their lives. Theyre watching relatives that are passing away or being so ill that they need to go to the hospital. They have tremendous disruption in their roles and routines. They see polarization in leaders with disagreements between parents and schoolteachers on what it is they are supposed to do, and theyre having a very difficult time also with social isolation but not necessarily because of the isolation per se but because of the time that kids are spending on social media instead, which we now know has incredibly dangerous effects not only on Kids Development but on the development of kids brains during that time. This is a very big issue and very concerning. It also is an opportunity. This is a time when we have people talking about Mental Health like they have never talked about before. And people are recognizing the need for us to be addressing Mental Health before it reaches the acute crisis of people needing to go and get outpatient or inpatient treatment. This is an opportunity for us to really build in at the fabric of how we educate, how we talk within our communities the importance of Mental Health and resilience programs. Our entire Mental Health system right now is built for adults. Its built, also, for people who are already at the point in a crisis and need treatment. That is not what the science suggests. What we could be doing now and what this presents us with an opportunity to do is to Pay Attention to all of those folks who are at risk or who have not even shown any psychological symptoms yet and build the resilience necessary to ensure that they will never need outpatient or inpatient treatment. That is what were seeing with kids right now. Theres a wide openness to talking about these issues, and kids, just as ms. Rhyneer was talking about so eloquently, want us to step up and teach them information about Mental Health so they can learn the skills before they reach a crisis point. Thank you. Dr. Goldsby, my time has almost expired, but an estimated 636 people in maine died from drug overdoses last year. That is a terrible and alarming record high. But what it obscures is the actual number of overdoses which was in the neighborhood of 8,000 overdoses in the state of maine, where thanks to the horrific efforts of First Responders, medical professionals and sometimes bystanders, they were saved. How can we ensure that nonfatal Overdose Patients are not just a statistic and receive the care they need to prevent a subsequent and potentially fatal overdose . Senator collins, we talk about overdose reversal in South Carolina as an intervention and its in that moment when somebody has faced a life threatening situation that they may be best reached by someone who offers them hope, hope to live, hope to a path to recovery, and, i think those Intervention Services are key as we do more outreach, as we have our First Responders saving lives, taking advantage of this critical crisis moment to engage people in services that will lead them on a path to longterm recovery. That can look a lot of different ways but its taking advantage of that moment, that lifesaving moment that we really engage in Treatment Services. Thank you. Thank you. Senator baldwin. Thank you, madam chair. In 2019 i introduced the bipartisan National Suicide designation act which was signed into law in 2020. Converting from the existing tendigit number to 988 will make it easier for americans to get the help they need and im proud of the investments included in the American Rescue plan to support this transition. Dr. Lockman, as you know the 988 dialing code will be available nationally for calls, texts, or chat beginning in july 2022. What else should we be doing in congress right now to make sure that the life line is equipped to facilitate real access to care . And, how can we make sure the life line reaches those in greatest need including our lgbtq youth . Thank you so much for that question, and thank you for your support. As you know, the avenue of 988 opens up access to mental care providers in ways they havent before. There are a couple of things i think of in terms of what we can do to make sure that we are prepared for this transition. The first one is to make sure that everyone has access on the crisis call line to the very best in training. We know that the science advances so fast, and there needs to be continued training and retraining to make sure were using the very best practices to take care of people. For example, we rarely use language such as committed suicide anymore because it denotes that its a crime. Instead we say died by suicide, and thats important for someone to know. We also talk about things such as its important to not die, not just for the sake of not dying but for the sake of having time to republic cover the life that you really want to live. One thing is making sure theres continued investment and support in making sure every Single Person whether youre the person that a caller they text is ready and equipped to provide evidence based practices, interventions, and the language around Suicide Safer care. The other thing i think about in terms of making sure that everyone is equipped to reach a care provider who cares about them including our Lgbtq Community is making sure that we are using inclusive language and the messaging around 988 and making sure everyone knows that they have a safe place to go when theyre talking about suicide. Weve seen in our own programs including serving this community that talking about connectedness, talking about Mental Health wellness, talking about meaningful living, and as others have testified, moving the language more upstream to where everyone has a place to grow and become their very best self. This language is likely as important as reducing suicide and so thank you for your attention to this very important transition. The third thing i will say is we need to make sure were building out the entire crisis continuum. 988 is the starting place but there are plans to making sure our mobile criseses services are well equipped and well trained and making sure that we are helping other infrastructure. Theres over 600 csus or crisis stabilization units operating in the United States right now. That provides a really important and critical part of the crisis continuum to make sure that there is diversion from Emergency Departments. The Emergency Departments are wonderful in terms of being able to when people are well trained, to address and prevent suicide. But csus have a different model. They have a living room model to where youre coming in and treated from a standpoint of recovery from the beginning and also treated with peer support, with a focus on growing and wellness and recovering from suicide or Substance Abuse or other concerns. I thank you for your support in making sure we are building up the entire continuum to make sure they reach to someone well trained but can put them on the path to longterm growth, wellness and wellbeing. Thank you. Dr. Prinstein, it sounds like you would like to also reply. Please do. Thank you. Ive spent the last 22 years doing research on suicidal youth. Those who are at most risk and thank you so much for the work youve done to establish 988. It is incredibly important that when folks call, of course, theyre getting treatment thats likely to work. We now only have science to support one approach to treatment, and the vast majority of folks are not trained in that approach. Its very, very important that we increase the training of providers. In addition its important that we have culturally competent providers so folks are able to call and understand the embeddedness of suicidal thoughts within their communities. When ive done that research we found suicidal participants would call 10, 12 outpatient providers and not be able to find anyone who would take their case. We need more people trained in super side. We need more people trained to deal with the scientifically evidencebased approaches to suicide in particular. Happy to help in any way that we can. Thank you. Senator . Great to see you, dr. Durham. Dr. Durham is a former student. Im recognizing a mardi gras tie. Trained in new orleans. Everyone else thinks i cant match colors. Dr. Durham, you mentioned you opened a 56bed facility. Now i understand that massachusetts has a waiver from the ind exclusions. And, you know, imd which says you can only have 16 beds in your facility, and the issue here is both cost but the perception of going back to the bad old days when we put people in a big warehouse for the mentally ill and not let them out. You mention as a positive that youre going beyond the 16 beds to 56 beds. Can you speak to the importance of that waiver or that ability to go above 16 . I assume these are medicaid patients. Yes, many of them will be thank you, senator cassidy, again good to see you as well. Many of them are medicaid medicare and we do see a very small number of privately insured folks at bmc. Bmc is a large safety net hospital for the city of boston and beyond boston and we have never had our own inpatient psychiatric unit. So that has caused increased boarding in our own psychiatric emergency room and emergency room period for decades. So a big investment of the hospital is, like, where do we send our patients who are on medicaid or medicare, because many of the facilities in and around boston are also full and at capacity. And so it was an investment for our patients essentially. So just to be sure, unlike the kind of stereotype and the criticism that if you go beyond 16 beds you are just warehousing, here you find that you are able to provided needed service that is otherwise would not be available, correct . Im not familiar with what you are talking about exactly, but we do need a continuum of care for Mental Health. So we need investment in community and intermediate resources and inpatient level of care so across the continuum. And over 16 beds allows you to an economy of scale as well as to provide more services . Ill add that editorial because thats something for we policy makeers to consider, just to say that. Dr. Lockman, in your full testimony, you mentioned the teleMental Health bill that were trying to push out. And can you kind of comment upon the ability of allowing teleMental Health to address the person power shortage of providers that was previously referred to . Absolutely. When the pandemic hit at centerstone we had never used teleMental Health widely, and we couldnt actually find research to understand the degree to it being effective particularly in our population. Our population has a lot of Community Based needs, a lot of social barriers and a need to reach them quickly. We have done our own research in terms actually in part through the grant and are thankful for the funding and providing services via phone or telehealth has about the same outcomes as being seen facetoface. This has allowed us incredible mobility during the time of the pandemic. Its allowed our providers to see more patients. Its also allowed more people to come and have better access to care that really transverse as lot of psycho social barriers. Im running out of time. To cut to the chase, you would highly recommend Congress Pass my bill . We highly support Telehealth Services and phonebapsed services for Mental Health purposes. Sounds great. Dr. Prinstein, you highlight the importance of programs such as the programs for children with a serious emotional disturbance, which senator murphy and i were able to get passed as part of a bigger piece of legislation, and the community Mental Health block grant targeting funds that children with serious emotional disturbances. Now weve heard from states that because it is perceived that the child has to have a diagnosis of serious emotional disturbance before they would qualify to benefit from these funds that we should make it clear that the funds could be used for Preventive Services to prevent a child from development sed, if you will. Any comment on that . Yes. First of all, thumbs up on the teleMental Health improvement act. Excellent, science support that is is working. Second, yes, theres a huge backlog right now for folks who are wait to go get an individualized educational plan, sometimes waiting years until they can get the diagnosis so they can access those funds. So i agree having the ability to access those funds through Preventive Services would be fantastic. Okay. Im almost out, ms. Rhyneer, thank you for what you do. As someone who has familys affected by suicide by a young person im sorry to be emotional. Thank you. I yield back. Thank you. Senator murphy . Thank you to this tremendous panel. Thank you, madam chair, for convening this hearing. Thank you, senator cassidy, for your heroic work, standing up for people with Mental Illness and learning disabilities. And if i can just for a moment lift up a piece of legislation that senator cassidy and i worked on and this committee supported. We passed legislation through this committee making real the Mental Health parity legislation. The reality was we told plans to cover Mental Health just like you cover health for the rest of the body, but it didnt work out that way. Plans ended up putting up all sorts of barriers and bureaucracy and red tape in front of getting reimbursement for Mental Health that they didnt for an orthopedic procedure or an operation on your heart or lungs. One of the things we did a few years ago is require the department of labor and department of health and Human Services to do an audit of a select group of Insurance Plans, and we just got the report. Its both defeating and encouraging. It basically came to the conclusion that not a single Insurance Plan that they reviewed was in full compliance with parity, but through these audits they actually got the plans to change their practices and parameters such that tens of thousands of Mental Health consumers are getting what they paid for when they paid their insurance premiums. An example is one Insurance Plan was covering nutritional therapy for diabetes but was not covering it for anorexia, bulimia or binge eating. Another plan was requiring preauthorization for all outpatient procedures for Mental Health and substance april bus but was not requiring it for a broad range of orthopedic procedures. So were finally getting this right. I wanted to maybe pose this question to you, dr. Durham, to talk a limb bit about your experience in dealing with insurance companies, and families trying to get reimbursement and the differences you see in a big medical system in the way that barriers are put up when it comes to Mental Health and Substance Abuse that just dont exist when youre going to get the followup treatment on an operation on your knee. I think were making progress here, thanks to this committee, but i think we still have a long way to go. Thank you, senator murray, for your question. I agree completely that none of this is new to us that are on the front lines, that are serving patients day in and day out. I have not read the report fully but i understand all in all insurers are not allowing us to treat people with the best evidence at all times, whether thats medication, whether thats therapy, whether thats trying to get them into another facility for more intense care. And so what happens in our emergency room for an example is that we do have to get what we call a prior off, prior to sending someone off to a psychiatric facility. You would never do that with someone who comes in with a heart attack to the emergency room. They immediately go and get the help they need on the medical floor, and no questions asked. And so we spend hours sometimes. Our social work colleagues, ourselves, our case managers in the emergency room just trying to get someone placed. And at times to the level of where someone like mean as a physician has to do a doc to doc to essentially say our case, why do we want this patient to go into an inpatient psychiatric unit and sometimes were denied. The outpatient world as well, im a child psychiatrist and i see kids in the clinic and have been on the phone with an insurer as well when a medication adjustment needs to be made, for hours. My time in the clinical setting where i should be seeing patients is spent on the phone trying to essential lip get a kid that was always on a medicine but the formulary changed and i want them to continue that medicine. Weep need a lot of help in the area. We need to have parity for physical and Mental Health and not have to be at the beck and call, if you will, of these prior offs. Very well said. And this is an issue i know there will be bipartisan agreement on because were just asking for compliance to the existing law. We dont have to pass a new requirement on insurers. We need to give the tools to the departments to make sure the insurers comply. Im going to submit a question for the record to the panel with respect to how we get more professionals who are in contact with kids a little bit of extra learning on Mental Health for state. We spend hours of training for teachers and pediatricians and we could do better by giving additional help on identifying some of the root causes. And lastly, let me just say thank you to you, ms. Rhyneer. Thank you for speaking truth to power on this issue and for standing up for kids. Im a parent to a teenager and a preteen, and so i see the rabbit hole that kids can go down when they are experiencing those first signs of crisis, given how online some pretty toxic information and influences are, and inthink youve opened our eyes to that with your testimony today. Thank you, madam chair. Thank you. Senator braun . Thank you, be madam chair. In march of 2021, American Rescue plan was signed into law, 4 billion to address the Opioid Epidemic. But with that and the lack of anything substantive in terms of trying to crack down on the source, fentanyl is mostly made in china, trafficked through mexico. Listen to these statistics. I want the public to hear it mostly. 100,000 americans have died in the last year due to overdoses. Many of them, if not most of them, from fentanyl. This is the part that is most shocking. In the age group 18 to 45, weve lost more young people from overdoses than covid, Car Accidents and suicides. So its another example of where spending money was not the solution without real teeth, real substantive directives at the source of it. We visited the southern border a little less than a year ago. And we were going from record low illegal crossings to about 70,000 to 75,000. Thats now leveled out at about 170,000. I mean, appalling. I have two questions, both for ms. Goldsby. When it comes to not only the impact on losing lives but along with workforce to boot i think weve lost close to 2 million prime age workers due to the fact theyre contending with opioid issues, how much of this issue is directly related to the policies we have on our southern border where illegal crossings are up, fentanyl comes along with it . How much has that contributed to this tragic loss of life . Senator braun, thank you for your question. You know, a couple of things. My expertise rests with prevention treatment and Recovery Service delivery, but, you know, from 2018 to 2019 in South Carolina, we were really making headway and saw the number of overdoses leveling off due to alm of our efforts and all of the federal funding with state target and state opioid response funds. Since then, in the last two years, our overdoses have skyrocketed, and were estimating about 63 of our overdose fatalities in 2020 were a direct result of the extremely potent illicit fentanyl in the drug supply. I think in the last two years we have pivoted to doing everything we can to keeping people alive and implementing evidencebased Harm Reduction and Intervention Services. Weve got naloxone and the federal support we have Fentanyl Test strips to those individuals who may not know what substances theyre ingesting as the illicit fentanyl is in the meth and cocaine supply and the evidence suggests that people are better able to prevent an unintended overdose death if they use these Fentanyl Test strips, using less of the drug and every interaction to get the supplies to people on the streets where they are is an opportunity to engage them in Treatment Services and get them on the path to recovery. Thats where our efforts are focusing heavily now and i will say were not feeling defeated but its been a major setback in the last couple of years how dramatically things have shifted. Thank you. I think without directly saying so by deduction you can relate whats happening on the southern border to what youre grappling with. Senator markey and i have two pieces of legislation about increasing provider and patient education. One is the label opioid act and safe prescribing act. Through your work in addressing the Opioid Epidemic can you speak to the importance of provider and patient education and how these bills might impact that . Ms. Goldsby . Senator braun, thank you. Sorry. I think the patient and provider education is key and we have a long way to go especially with our provider education and all of our health Care Workforce. I think its been a theme today that weve talked about folks not understanding addiction and Mental Health issues as disorders, addiction issues as chronic diseases, and the evidencebased services, interventions, and treatment models that address these disorders successfully. And so weve come a long way. Weve invested a lot in our response and in engaging the workforce as such. I know that we have a long way to go especially as we contemplate access and what that means for people approaching Health Care Providers who dont or dont nope how or dont address addiction appropriately. Thank you. Id like you and the other members of the panel to take a look at these two bills. It would be a small step in at least trying to get more information out there and to weigh in on maybe endorsing both of these pieces of legislation. Thank you. Thank you. Senator kaine . Thank you, chair murray. What an excellent panel of witnesses, and my colleagues have asked very, very good questions. I want to first put a challenge on the table that i may be asking my colleagues to help us resolve. Two officers who were here defending the capitol on january 6 died by suicide in the days right after that attack. One was a Capitol Police officer and Jeffrey Smith was a metro police officer. Two other Metro Police Officers died by suicide a number of months later. I dont mention them because their families have not reached out and asked for help and i dont want to presume their intentions. But the families of officer smith have reached out for help. Officers federal, state and local are generally accord add death benefit should they die in the line of duty, but Law Enforcement officers death benefits usually state that a death by suicide cannot be a death in the line of duty. That is a significant injustice its often hard to determine if a death is in the line of duty. If a Law Enforcement dies of cancer, they have to go back and determine, well, was the officer exposed to a toxic substance in the line of duty, or is it related to Something Else . But to declare categorically that no death by suicide can be a line of duty death is a fundamental injustice in both the smith and liebengood families are taking that up with the respective benefit plans under win they served. In the military suicides are not. An overwhelming percentage of death by suicide of active duty military, they get investigated and the overwhelming percentage of the cases they are determined to be line of duty deaths. Theres an unjust and antiquated view of suicide affecting these line of duty death determinations. There are two who served at this capital and died by suicide in the days after the january 6 attack. They have ongoing proceedings going before the relevant authorities, and so it might be slightly premature. We may need to address this by a matter of law in the same way weve allowed active duty military, Law Enforcement officers should not be shut off from that. I want to ask each of you about a passion of mine shared by members of the committee and that is the Mental Health of our healers, keeping our healers healthy. Prior to the pandemic there were escalated rates of suicide compared to the general population. And many medical professionals feel some significant stigma about seeking Mental Health counseling because of worrying about credentialing at hospitals or licensing at the state level or what colleagues might think. Committee colleagues have joined together with me in a bipartisan way to pass an act which i introduced with others on this committee named to commemorate a very talented Emergency Room Physician in new york, a virginia native who died by suicide at the beginning of the real wave of pandemic in april of 2020. But what can we do in the profession to help our healers feel more able to get the help they need . Sure. Thank you, senator kaine, for bringing that up, and thank you for your work in this area. It is, in fact, very important. We are definitely seeing burnout. The Mental Health care providers are frontline workers, too, and were seeing major burnout among Health Care Providers. In partnership with the cdc, the American Psychiatric association has been providing help for those experiencing burnout and need psychological First Aid Training but also are quite angry and are feeling really challenged by the amount of harassment that they are getting, the amount of victimization they are subjected to for treating folks due to covid, for offering vaccines, and a remarkable amount of frustration for the patients they cant get the opportunity to treat because theyre overrun with folks who are experiencing covid and are unvaccinated. There are a variety of things that can be done. As you ask providing concrete support, modeling selfcare, psychological First Aid Training as i mention. I wanted to thank you for both of your points, really raising this issue of stigma that is still pervading the way we think about Mental Health issues versus physical Health Issues and i hope this committee can be very, very clear thats sometimes also reflected in the amount of funding that we provide to develop a workforce in Mental Health versus physical health care and that just has to stop. Thank you. My time has expired. Thank you, chair murray. Thank you. Senator marshall . Thank you, madam chair. I want to lock in on prior authorization. My first question is for dr. Durham. Prior authorization is the number one Administrative Burden facing physicians today across all specialties. Prior authorization, the number one Administrative Burden facing all physicians across all specialties. As a physician myself i knew of the frustration of having to do this, talk to a person who may be a nonspecialist who wasnt from my area. I couldnt imagine trying to do a prior authorization and couldnt imagine doing that. But this burnout is leading to early retirement. It ties up nurses. Its frustrating to nurses as well. It makes us all less productive. I guess and you spoke about this earlier, prior authorization. My question is do you ever feel that prior authorization is used to ration care or to delay the care the patient needs . Thank you so much for your question, and as a fellow physician that you understand sort of what were going through. I do think it delays care. Absolutely especially in the emergency room context. We have literally two to three hours sometimes just to get someone a bed because were waiting for the insurance to respond to give the okay that, yes, what you have presented to us meets the criteria for us to get a patient an inpatient psychiatric bed. So without a doubt it delays care. We have a lot of patients weep need to see. I talked briefly in my testimony about weve been beyond capacity in our Emergency Rooms, and i think thats not unique to bmc but across the nation during this crisis that people are going in for emergency services. And so awaiting beds, awaiting placement, just clogs the system, if you will. Thank you. My next question for dr. Prinstein, were going to stay on the same subject of prior authorization. If there was a streamline solution, would it be helpful to your specialty streamline meaning i would suppose that ten diagnosises account for those that need to be prior authorized. We have 17 sponsors including eight democrats, nine republicans, 450 nation and state organizations are sponsoring this legislation which would streamline the prior authorization. Would it be helpful for members in your specialty . Yes, i think it would. Psychiatrist represents a small percentage, 10 of the workforce, and thinking of solutions that include all meantal Health Providers is appreciated. Thank you. You bet. My next question for ms. Goldsby, you work in the department of alcohol and drug abuse services. Does prior authorization ever impact your patients . Does it delay care or ration care . We sometimes do see prior authorizations delaying care particularly for some patients who have Insurance Benefits when theyre needing to be placed on medications. And a streamline approach to those patients would be beneficial to your staff . Yes, absolutely. No barriers to treatment, yes. Dr. Lockman, kind of the same issue, prior authorization, i know youre doing research more research based. Do you ever sit there and think about where some of your research leads you to, will have patients access to it . An Insurance Company deciding what that patient should be receiving . Absolutely. I concur. Every single hour that we spend navigating preauthorization to get a patient the evidencebased treatment he or she needs is an hour that could be spent on Something Else, delivering the care that changes peoples lives. It could be spent on also doing the training that you have mentioned as critical. Any way we can cut down on the processes would be helpful to where we can give people the treatment that they need. Thank you so much. Ill go to ms. Rhyneer. Im not going to ask you about prior authorization. So thats a good thing. I guess my question for you is have you experienced some of the mandates, whether its a mask mandate or Vaccine Mandate closing down schools, how has that impacted the Mental Health of your costudents . I think theres been some silver lineings and covid has exacerbated and introduced new issues. During Typical High School class as teacher is one of the first lines of defense. They can catch changes in a students behavior, performance or attitude. I stared at a screen of gray squares. The teachers found fewer opportunities to ask, hey, are you okay . How are things going at home . You seem a little off. Is there anything you want to talk about . So thats kind of one bad thing. But a Silver Lining on the other hand is, like, i think the conversation on Mental Health has become a little bit more comfortable, and so teachers have been, you need a selfcare day. Take the day off. Take a walk. Go do your own thing. Lets take the zoom class off for today. That was something totally okay to do. I think theres good and bad. I think im willing to stay at home for the safety of our community. I also know that for some families that makes it really hard, and for some families its not safe for the student to stay at home and school is kind of like the safety net to this security blanket to be away from that. That makes it tough. I dont know if theres a way to say that it was all bad or all good. Thank you so much. I yield back. Thank you. Senator hassan . Thank you, madam chair. And inthank you and the Ranking Member for organizing and approving todays hearing and to all the witnesses thank you for being here and for the work that you do. I want to start with a question to you, dr. Prinstein. Young patients are being forced to wait in Emergency Rooms for up to a month hoping an inpatient psychiatric bed will open up. Sometimes in my state its more than that. They have written to me recounting their experiences waiting in hospitals. They describe truly horrific experiences such as being kept in isolation and going weeks without showers let alone Mental Health care. The situation is so severe that New Hampshire used federal funds to purchase a local hospital to take these children out of the emergency room, but we know theres more work that still needs to be done and even with the purchase of this hospital and now additional beds, there are still long waits in our Emergency Rooms. What concrete steps can Congress Take to effectively reduce these wait times for urgent Mental Health care . Thank you so much for the question, senator. I appreciate it. It is the case that once someone, and especially a child, is experiencing imminent risk to themselves and others, they do need to be in a hospital. They do need the constant surveillance. And we might think that adding more hospital beds is the answer. It certainly is an opportunity to make sure we have enough emergency services, but the problem truly has to be addressed by offering more outpatient providers that can make sure that kids never get to that level of crisis. We have the treatments. We have the science to show that it works. We just need more people to administer those treatments and keep kids from getting to that emergency stage. 750 times more funding to make sure we have enough physicians in this country than what were providing 750 times than what were providing for our entire Mental Health Care Workforce. If we had that if we treated the likelihood that one out of every five young women will experience a major depressive episode before the age of 25 as we heard ms. Rhyneer say one out of four people in alaska will experience severe suicideality. What would we do if that was a physical health disorder. We would be training people what to expect and making sure everyone had access to treatment the first minutes they showed symptoms. Its happening for depression and the reason why all this is overrun in the hospital is because we havent provided the workforce to provide outpatient treatment before we reach the crisis stage. Thank you. Let me follow up on the points youre making with ms. Rhyneer and dr. Durham. Important we acknowledge the Mental Health in schools. You were talking about things opening up a little bit and people talking more about it. I received a letter from a student from New Hampshire sharing her experience. With what she considers a real lack of awareness in her school. She wrote in part schools and workplaces are not taking Mental Health seriously. We do not learn about Mental Health in school nor the workplace. I have seen first hand the way these disorders can affect people. Its not seriously talked about. Not taken seriously enough. Its powerful to hear students like this young woman talk openly about Mental Health and we need to do more to support them. Points you all have been making. How can we work with students to end the stigma around Mental Health . Ill start with ms. Durham. Theres a huge stigma in ethnic minority communities ask we need to start at schools, at home and partnering with other community organizations. The church, other systems of care that people go to other than healthcare systems. That we can start opening that dialogue and thinking more openly sort of like claire has done today, telling our stories. A lot of initiatives within Boston Medical Center with reaching out and partnering with our local churches. We have people in my department to start doing some of that work breaking down stigmas so people can come in for treatment. Thank you. Ms. Rhyneer. I totally agree. We can support community and local organizations. Some of the ones that i was in was i was introduced to yana, you are not alone and Mental Health advocacy through storytelling and they encouraged me to tell my story. It is youth led and youth founded and a group of High School Students working to decrease stigma and increasic a ses to Mental Health resources through true personal health stories. And we run a 12week program twice a year aiming to teach and guide conversations on Mental Health and storytelling and help participants develop their own stories on Mental Health and all of our participants share their story kind of in the style. Helping organizations and promoting them and encouraging them and funding them and things like that is really, really important. It was my own friends at this organization who taught curriculum and helped me tell my story and its because of those resources and that education that i opened up to my parent last year and the reason why im here today. Thank you. I realize im out of time. Ill follow up with you, ms. Goldsby. Thank you, madam chair. Thank you, senator smith. Thank you so much madam chair. Id like to start by asking unanimous consent to submit for the record a letter from council 60 and council 65 for the need of Sustainable Solutions and longterm investments in the Mental Health Care Workforce. Chair murray and senator murkowski, im so thankful for you holding this hearing and bringing the experts and colleagues to dig into Mental Health and Substance Abuse disorder. This is an epidemic as we heard today that is traumatizing our country. And dr. Prinstein said it so well. This emergency is related to covid, but it is the result of decades of systemic neglect and lack of attention and bifurcating mental and physical health to the detriment of our whole health. And i can tell you, of course, i hear about this from minnesotans every single day. Educators and parents and students especially who are grappling with significant Mental Health conditions. And, you know, i want to share that this is personal for me for two reasons. The first is that my mentor Paul Wellstone who once held a seat that i have today led on this issue with senator new mexico senator and through their leadership Congress Passed legislation to get parity for mental and physical Health Reimbursement in the medical Health Care System. As we heard today were still climbing up that mountain to get compliance for Mental Health parity and we wont stop until we do. But i want to just note their leadership which was instrumental. And the second reason that this issue is personal to me is that i experienced depression when i was a young person starting in college and then again when i was a young mom. So, i know a little bit about what it feels like to feel like there is something fundamentally wrong with you and there is nothing that can be done about it. There is no solution. And, you know, i share my story because i want to, im thinking about people who are currently suffering from Mental Health challenges and feel like theyre all alone and nobody knows. And that they cant talk about it because of the stigma. So, ms. Rhyneer, i want to particularly thank you for your testimony and for sharing your story. Senator murkowski knows that i actually also went to East Anchorage high school, so we have a little bit of anchorage in common, as well. But let me go, im going to stay with you, ms. Rhyneer, i want to talk about Mental Health care in schools. Last month the university of minnesota released some data that said that 71 of principals in minnesota are saying that more Mental Health resources for students would be the most important support that they could get. And i visited schools and ive seen how this works and what a difference it can make. So, ms. Rhyneer, could you talk to us about why inschool services are important and why they work for students and kind of how you see they might get at the stigma challenges and other challenges that students have accessing the Mental Health care that they need. Sure, yeah. So, well school is a great place just because it is a place where all students are going to be and you can do a lot of Different Things in schools. You can have the community and the teaching and peers and you can have adults all working together. And your parents, too. And also, you know, we have counselors and we want to have counselors and therapists in schools. But, also, you know, having the curriculum around is really important. You know, ive talked to numerous students who say they didnt realize how bad a situation they were until years later. Like they never recognized their own systems and they never reached out for help. So, having curriculum in schools is great to help people recognize their own symptoms and be like, oh, i think something is going on. I need to reach out to somebody. That person they need to reach out to this room down the hall that they can walk down there and say, hey, i really need some help. That counselor can call the parent and be like, hey, i talked to your kid. Maybe you should talk to them. So its a really great place to have all those services in one place. Its such a great way of describing what difference it makes and, also, i would say how we can really integrating physical and Mental Health. Maybe you go in to see the school nurse about a stomach ache and then the school nurse asks some questions and understands what you really need, underlying issues around anxiety or depression and it happens all in one place and the kind of integrated care that we heard the experts and physicians on the panel talk about. Madam chair, as you know i am sure you know that i have several bills that i have been working on that would expand access to Mental Health Care Services in schools and im going to be very interested in pursuing these bills and this legislation as we go forward for exactly the reasons that claire just described. Thank you. Senator rosen. Thank you, madam chair. And thank you, senator murkowski, for holding this really important hearing today and, of course, for the witnesses for being here. I want to build on what senator smith was talking about because it is important that we eclipse schools with the Mental Health and Suicide Prevention resources that are critical because not just senator smith but we heard from everyone our schools and students are facing such a growing Mental Health crisis and the American Academy of pediatrics recently declared a National State of emergency in childrens Mental Health and in nevadas Clark County School district, weve tragically lost 20 students. 20 students to suicide since the onset of the pandemic in 2020. Families will never be the same. So, we must do more to keep our students safe, to promote their Mental Health and their well being, which is why as senator murkowski noted earlier, im working with her on Bipartisan Legislation to help provide Additional Resources to support k through 12 Mental Health and currently the Substance Abuse Mental Health Services Administration or samhsa does not have the authority to provide fundal assistance directing School Districts to promote comprehensive health and Suicide Prevention services. So, dr. Prinstein, given the current Mental Health crisis in our schools, could legislation authorizing samhsa to directly provide targeted and timely resources to k through 12 schools help prevent the Mental Health challenges before they occur and, of course, address suicide attempts and prevent a suicide from taking place . Yes, senator rosen, thank you so much. Hooray, this is a great step and very, very important. The opportunity to make sure that schools themselves can use their local expertise and their knowledge of what their Community Needs is a fantastic idea. I will say please do keep in mind that school staff are currently overwhelmed and usually turning to psychology, as well as other Mental Health care providers to teach them about the skills that are needed. Psychologists often do this out of the goodness of their own heart. There is no reimbursement mechanism. As they becomes a more widespread practice of schools instituting preventive programs throughout entire communities, please do think about ways that psychologists and other Mental Health care providers can be as helpful and dedicate as much time as possible to help teach the school staff whats needed, to use our evidencebased assessments to screen for risk and to use our evidencebased interventions so we can help as many people as possible. We have many prevention programs ready to deploy and this is a very exciting opportunity that youre speaking of. Thank you. Well, you set me up perfectly for my next question. Because all 17 counties in nevada are designated health shortages and university of nevada reno providing counseling k through 12 students and hopefully doing some of that other training when theyre in the schools that you speak of. And this Partnership Allows our unr interns to gain realworld experience in a supervised setting while also increasing the access and just the Knowledge Base for everyone in those schools, particularly right now in churchill k through 12 students. Again, dr. Prinstein, this is a model were using it in nevada. How might this model or others that you see, not just in nevada, how can we lead the way in helping to promote these kinds of partnerships that will address the burn out and critical shortages and give those benefits to the students and teachers, as well, counselors. I think it would be terrific if we had the workforce to be able to do that in all states. Imagine there were School Psychologists enough to deploy and consult with every school out there, not just one per School District or one per county. Sometimes with kids waiting for years before theyre able to get an evaluation. Meanwhile, their parents watch them failing grades and experiencing difficulties just waiting for that School Psychologist to join in. Theres sometimes only one Mental Health care provider for an entire county or for 100mile radius which makes it very hard to consult with all the School Districts to ask us to play a role in just the way youre describing. I think this approach coupled with a substantial increase in the workforce could really be a wonderful model for us to try and change the way that were thinking about Mental Health from a prevention approach, as well as an intervention approach. Well, thank you. I appreciate that. And i look forward to working with all of you and my colleagues to promote workforce training in the Mental Health space. We really need it in so many areas. Thank you, madam chair. Thank you. We do have two votes called. Those are all the senators who have questions. Senator murkowski, do you have any Closing Remarks . Just very quickly, madam chair. I agree, this has been an excellent, excellent panel. When we think about the issue of the issues of Mental Health and Substance Abuse disorders, so much of the response has to be when the individual is ready for it. It needs to be the intervention at that moment and i was struck. I keep going back to reading claires testimony and, claire you indicate i worked at the association of national illness and i had to tell people they would be on a waitlist for 9 to 12 months before they would receive care from a caseworker. Three months before the patient would be contacted whether they could be accepted and another six months before they could talk to a case worker and begin care. When we talk about the workforce issues, we cannot have a situation, an emergency, a crisis and have an individual be told, it will be three months before we know whether you can even receive care. So, a lot of focus on the Mental Health issues. Ill tell you, dr. Prinstein, when you indicated that the United States is number one in the world for suicide rates, we think that money can solve a lot of things, but apparently were not directing the resources to those very critical areas of Mental Health like we need to. Apparently, we havent dedicated the resources for the workforce. Apparently, we havent connected with the younger people and, really all across the spectrum. We havent addressed some of the racial issues that you have pointed out here. So, we, obviously, have a great, great deal to do here. And i think that todays witnesses have provided us great insight but its a reminder that we have so much to do. So, thank you to all of our witnesses and look forward to working on these problems. Senator murkowski, thank you. Thank you for helping us put this together. Thank you to all of our witnesses. Senator murkowski, you talked about workforce. That clearly is an issue. A number of other issues were addressed. But i think you actually identified one at the very beginning which we dont talk about enough and that is how do we talk about suicide. I think there is, as you stated, among young people a willingness, a desire, understanding that this cannot be a taboo topic. In fact, we need to have an understanding of it. We need to have a discussion of it. But it is so hard for so many people to talk about it, as she said, because theyre afraid theyre going to encourage somebody to do it. We all have a learning to do and a lot of learning within our schools and across our communities to deal with this issue and i look forward to working with you, senator murkowski, on that and all of our colleagues. That will end our hearing today. I want to thank you senator murkowski for joining me today and for all of our colleagues for very insightful discussion and i really want to thank all of our witnesses dr. Prinstein, dr. Durham, ms. Goldsby, dr. Lockman and ms. Rhyneer. This committee will meet february 8th and challenges for people with disabilities. Meeting stands adjourned