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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. Key Policy Challenges and Opportunities to Improve Care for People with Mental Health and Substance Use Disorders: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25690.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

KEY POLICY CHALLENGES AND OPPORTUNITIES TO IMPROVE CARE FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS PROCEEDINGS OF A WORKSHOP Laurene Graig, Kaitlyn Friedman, and Joe Alper, Rapporteurs Forum on Mental Health and Substance Use Disorders Board on Health Care Services Board on Health Sciences Policy Health and Medicine Division PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by Contract No. 200-2011-38807 (Task Order No. 75D30118F00073) with the Centers for Disease Control and Prevention, Purchase Order No. 75FCMC19PO036 with the Centers for Medicare & Medicaid Services, Contract No. HHSH250201500001I with the Health Resources and Services Administration, Contract No. HHSN263201800029I (Task Order No. HHSN26300025) with the National Institutes of Health, Contract No. HHSP223014000020B (BPA to HHSP23337073) with the Substance Abuse and Mental Health Services Administration, Contract/Task Order No. 3610X18PO178 with the U.S. Department of Veterans Affairs, and by Alkermes, American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Council on Social Work Education, Education Development Center, Janssen Research & Development, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Otsuka America Pharmaceutical, PYA, and Well Being Trust. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25690 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Key policy challenges and opportunities to improve care for people with mental health and substance use disorders: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25690. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

PLANNING COMMITTEE ON KEY POLICY CHALLENGES TO IMPROVE CARE FOR PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE DISORDERS1 MARGARITA ALEGRÍA (Co-Chair), Professor, Department of Psychiatry, Harvard Medical School, and Chief, Disparities Research, Massachusetts General Hospital ALEXANDER ROSS (Co-Chair), Senior Behavioral Health Advisor, Office of Planning, Evaluation, and Analysis, Health Resources and Services Administration COLLEEN BARRY, Fred and Julie Soper Professor and Chair, Department of Health Policy and Management, and Co-Director, Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health JEFFREY BUCK, Senior Advisor for Behavioral Health, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services DARLA SPENCE COFFEY, President and Chief Executive Officer, Council on Social Work Education LORI DUCHARME, Program Director for Health Services Research, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health (until June 18, 2019) SUSAN ESSOCK, Edna L. Edison Professor Emerita, Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons LARKE NAHME HUANG, Director, Office of Behavioral Health Equity and Justice-Involved, Substance Abuse and Mental Health Services Administration R. KATHRYN McHUGH, Assistant Professor, Department of Psychiatry, Harvard Medical School, and Associate Psychologist, Division of Alcohol and Drug Abuse, McLean Hospital DEIDRA ROACH, Medical Project Officer, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health (as of June 18, 2019) MATTHEW TIERNEY, Associate Clinical Faculty, University of California, San Francisco, School of Nursing, and representing the American Psychiatric Nurses Association MIKE WEAVER, Executive Director, International Association of Peer Supporters TISHA WILEY, Branch Chief, Services Research Branch, National Institute on Drug Abuse, National Institutes of Health Forum on Mental Health and Substance Use Disorders Staff LAURENE GRAIG, Director, Forum on Mental Health and Substance Use Disorders, and Senior Program Officer KAITLYN FRIEDMAN, Research Associate RUHAMA GARI, Senior Program Assistant (September 2019–February 2020) MICAH WINOGRAD, Senior Finance Business Partner SHARYL NASS, Board Director, Board on Health Care Services ANDREW M. POPE, Director, Board on Health Sciences Policy Consultant JOE ALPER, Writer 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. PREPUBLICATION COPY: UNCORRECTED PROOFS v

FORUM ON MENTAL HEALTH AND SUBSTANCE USE DISORDERS COLLEEN BARRY (Co-Chair), Johns Hopkins Bloomberg School of Public Health SUSAN ESSOCK (Co-Chair), Columbia University Vagelos College of Physicians and Surgeons (January 2019–October 2019) HOWARD GOLDMAN (Co-Chair), University of Maryland School of Medicine (as of October 2019) MARGARITA ALEGRÍA, Harvard Medical School and Massachusetts General Hospital DARA BLACHMAN-DEMNER, Office of Behavioral and Social Sciences Research, National Institutes of Health CARLOS BLANCO, National Institute on Drug Abuse, National Institutes of Health MARTIN BROWN, PYA JEFFREY BUCK, Centers for Medicare & Medicaid Services DARLA SPENCE COFFEY, Council on Social Work Education MICHAEL COLSTON, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, U.S. Department of Defense W. PERRY DICKINSON, Practice Innovation Program, University of Colorado KAREN DREXLER, Office of Mental Health & Suicide Prevention, U.S. Department of Veterans Affairs THAD FLOOD, Otsuka America Pharmaceutical ROBERT FORMAN, Alkermes RICHARD FRANK, Harvard Medical School MICHAEL FREED, National Institute of Mental Health, National Institutes of Health CHELSEY GODDARD, Education Development Center ALTHEA GRANT-LENZY, Centers for Disease Control and Prevention PAMELA GREENBERG, Association for Behavioral Health and Wellness LARKE NAHME HUANG, Substance Abuse and Mental Health Services Administration KRISTIN KROEGER American Psychiatric Association HUSSEINI MANJI, Janssen Research & Development R. KATHRYN McHUGH, Harvard Medical School and McLean Hospital TYLER NORRIS, Well Being Trust KATHY PHAM, American College of Clinical Pharmacy DEIDRA ROACH, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health MARTIN ROSENZWEIG, Optum Behavioral Health ALEXANDER ROSS, Health Resources and Services Administration RUTH SHIM, University of California, Davis MATTHEW TIERNEY, Associate Clinical Faculty, University of California, San Francisco, School of Nursing, and representing the American Psychiatric Nurses Association RADM MICHAEL TOEDT, Indian Health Service MARVIN VENTRELL, National Association of Addiction Treatment Providers MIKE WEAVER, International Association of Peer Supporters PREPUBLICATION COPY: UNCORRECTED PROOFS vii

Reviewers This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: HORTENSIA AMARO, Northeastern University, Florida International University SHELLY F. GREENFIELD, McLean Hospital and Harvard Medical School Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by PATRICK DELEON, Uniformed Services University of the Health Sciences. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS ix

Acknowledgments The National Academies of Sciences, Engineering, and Medicine’s Forum on Mental Health and Substance Use Disorders wishes to express its sincere gratitude to the planning committee co-chairs Margarita Alegría and Alexander Ross for their valuable contributions to the development and orchestration of this workshop. We also wish to thank all the members of the planning committee, who collaborated to ensure a workshop complete with informative presentations and rich discussions. Finally, we want to thank the speakers and moderators, who generously shared their expertise and their time with workshop participants. Support from the many sponsors of the Forum on Mental Health and Substance Use Disorders is critical to the forum’s work. The sponsors include Centers for Disease Control and Prevention, Centers for Medicare & Medicaid Services, Health Resources and Services Administration, National Institute of Mental Health, National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, Office of Behavioral and Social Sciences Research, Substance Abuse and Mental Health Services Administration, U.S. Department of Veterans Affairs, Alkermes, American Board of Family Medicine, American College of Clinical Pharmacy, American Psychiatric Association, American Psychiatric Nurses Association, American Psychological Association, Association for Behavioral Health and Wellness, Council on Social Work Education, Education Development Center, Janssen Research & Development, National Academy of Medicine, National Association of Addiction Treatment Providers, Optum Behavioral Health, Otsuka America Pharmaceutical, PYA, and Well Being Trust. PREPUBLICATION COPY: UNCORRECTED PROOFS xi

Contents PROCEEDINGS OF A WORKSHOP 1 INTRODUCTION 1 PROMOTING PERSON-CENTERED CARE, SHARED DECISION MAKING, AND PATIENT AND FAMILY ENGAGEMENT 6 Flipping the Script: Advancing Patient-Centered Care and Supported Decision Making, 6 Trauma-Informed Care and a Ryan White Model of Delivery, 7 Creating Hope Through Person-Directed Care, Decision Negotiation, and Collaboration, 13 Discussion, 14 IDENTIFYING ESSENTIAL COMPONENTS OF CARE BY DEFINING WHAT MINIMALLY ADEQUATE CARE WOULD BE ACROSS DIVERSE CARE SETTING 16 The VA Integrated Care Experience, 16 Can We Provide Necessary Care for Substance Use and Mental Health Disorders in the United States?, 18 Considering Essential Components of Care While Maintaining a Focus on Behavioral Health Equity, 24 Implementation Science and Care for Substance Use and Mental Health Disorders, 27 Discussion, 28 PROMISING STRATEGIES TO TRANSLATE KNOWLEDGE INTO PRACTICE AND MONITOR IMPLEMENTATION 29 Harnessing Implementation Science to Realize the Promise of Evidence-Based Practice, 30 Using Evidence to Support Healthier Families and Better Lives, 32 MAT and SUD Treatment in Primary Care Settings: A Focus on Community Health Centers, 34 Integrating Primary Care and Behavioral Health Services in Coordinated Community Systems, 37 Discussion, 39 LUNCHEON DISCUSSIONS 39 KEY LEARNINGS FROM DAY ONE OF THE WORKSHOP 41 USING DATA TO IMPROVE CARE SERVICE DELIVERY AND PATIENT OUTCOMES 42 Examining the Opioid Epidemic Using Linked Data in Massachusetts, 42 Advances in Mental Health Measurement, 45 Achieving Population Well-Being Through Mental Health Integration and Team-Based Care, 47 Adapting a Data Infrastructure to Address the Opioid Epidemic in Camden, New Jersey, 49 Discussion, 51 DEVELOPING THE WORKFORCE FOR INTEGRATED CARE 53 The State of the Nation’s Behavioral Health Workforce, 54 Assessing and Expanding the Clinical Workforce for Treating Substance Use Disorder in Colorado, 55 Nurse Care Manager Model for Office-Based Addiction Treatment, 57 PREPUBLICATION COPY: UNCORRECTED PROOFS xiii

Social Work Workforce: Spanning Multi-Focused Care Delivery Systems, 59 Discussion, 60 REFERENCES 63 APPENDIX A: Workshop Agenda 69 APPENDIX B: Statement of Task 75 PREPUBLICATION COPY: UNCORRECTED PROOFS xiv

Boxes, Figures, and Tables BOXES 1 Suggestions Made by Individual Workshop Participants for Addressing Key Policy, Challenges to Improving Care for People with Mental Health and SUDs, 2 2 Caring for Pebbles, 9 3 Changes Needed to Treat More Patients Adequately in Primary Care, 18 4 Brief Summary of the Workshop’s Luncheon Discussions, 39 FIGURES 1 An evidence-based model of trauma-informed health care, 12 2 The WHO Service Organization Pyramid for optimal mix of services for mental health, 20 3 Treatment approaches, necessary components of care, and evidence-based policy to better address the opioid use disorder epidemic, 21 4 A model of how social determinants can lead to adverse mental health outcomes, 24 5 Percentage of adults with no health insurance coverage by race and ethnicity, 26 6 Percentage of Americans saying they have been personally discriminated against when going to a doctor or a health clinic because of their race, ethnicity, gender, or LGBTQ identity, 26 7 Five components to Philadelphia’s work implementing evidence-based treatments for mental health and substance use care, 31 8 Opioid-related overdose deaths in Massachusetts, 43 9 The Camden Coalition’s 16 domains of care it uses to engage individuals in bedside care planning, 50 10 Health care utilization outcomes at Massachusetts nurse care manager sites for office- based addiction treatment, 57 TABLES 1 The Characteristics of Effective Trauma-Informed Care, 10 2 Barriers to Substance Use Disorder Treatment, Initiation, and Engagement and Potential Solutions, 22 3 Structural and Societal Barriers to Combatting the Opioid and Drug Use Epidemics and Potential Solutions, 36 PREPUBLICATION COPY: UNCORRECTED PROOFS xv

Acronyms and Abbreviations ACE adverse childhood experience CAT computerized adaptive testing CAT-MH computerized adaptive testing-mental health CBO community-based organization CMMI Center for Medicare & Medicaid Innovation DoD U.S. Department of Defense ECHO Extension for Community Health Outcomes HRSA Health Resources and Services Administration MAT medication-assisted treatment MHSUDS mental health and substance use disorders NAMI National Alliance on Mental Illness PTSD posttraumatic stress disorder SAMHSA Substance Abuse and Mental Health Services Administration SUD substance use disorder UCSF University of California, San Francisco VA U.S. Department of Veterans Affairs WHO World Health Organization PREPUBLICATION COPY: UNCORRECTED PROOFS xvii

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Behavioral health and substance use disorders affect approximately 20 percent of the U.S. population. Of those with a substance use disorder, approximately 60 percent also have a mental health disorder. Together, these disorders account for a substantial burden of disability, have been associated with an increased risk of morbidity and mortality from other chronic illnesses, and can be risk factors for incarceration, homelessness, and death by suicide. In addition, they can compromise a person's ability to seek out and afford health care and adhere to treatment recommendations.

To explore data, policies, practices, and systems that affect the diagnosis and provision of care for mental health and substance use disorders, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine created the Forum on Mental Health and Substance Use Disorders. The forum activities are expected to advance the discussion and generate potential ideas on ways to address many of the most persistent problems in delivering mental health and substance use services. The inaugural workshop, held October 15-16, 2019, in Washington, DC, explored the key policy challenges that impede efforts to improve care for those individuals with mental health and substance use disorders. This publication summarizes the presentations and discussion of the workshop.

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