Behavioral Health During the COVID-19 Pandemic: Overview and Issues for Congress

Behavioral Health During the COVID-19 Pandemic: Overview and Issues for Congress

Behavioral Health During the COVID-19
July 2, 2021
Pandemic: Overview and Issues for Congress
Johnathan H. Duff
Circumstances surrounding the Coronavirus Disease 2019 (COVID-19) pandemic—including
Analyst in Health Policy
mitigation strategies to prevent spread of the virus—appear to have adversely affected the mental

health of many Americans. According to some studies, Americans experienced elevated levels of
Amanda K. Sarata
emotional distress, anxiety, depression, substance use, and drug-related overdoses in 2020 and
Specialist in Health Policy
2021 compared with the same time period in previous years. Various stressors related to the

pandemic may have contributed to decreased mental well-being, such as fears about contracting
the virus, anxiety about its health effects, social isolation due to physical distancing measures,
Paul D. Romero
financial stress due to the economic consequences of the pandemic, grief and bereavement due to
Research Assistant
the death of a loved one, exposure to pandemic-related media coverage, and interruptions to

substance use treatment and mental health care.

The physical distancing measures and temporary stay-at-home orders used during the COVID-19
pandemic have changed service delivery for mental health and substance treatment. Such changes include relaxing privacy
requirements required by the Health Insurance Portability and Accountability Act (HIPAA) rules and increasing the use of
telehealth to deliver behavioral health treatment and services. Some states have employed other methods of service delivery
(e.g., mobile units) for treatments that cannot be administered via telehealth, such as medication-assisted treatment (MAT)
for opioid use disorder. Congress has appropriated additional funding for behavioral health -related activities during the
pandemic in a series of supplemental funding measures—such as the Coronavirus Aid, Relief, and Economic Security
(CARES) Act (P.L. 116-136)—and the American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) budget reconciliation
measure.
Behavioral health changes during the COVID-19 pandemic pose a number of issues for Congress to consider. As the
pandemic continues, the federal government may consider whether to extend—or make permanent—some of the regulatory
changes to behavioral health treatment. In addition, Congress and other government institutions at the federal, state, and local
levels may consider the potential mental health effects of COVID-related polices such as stay-at-home orders and
asynchronous learning for students. Other considerations include oversight of the supplemental funding and of federally
supported behavioral health activities during the pandemic and beyond.
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Contents
Introduction ................................................................................................................... 1
Behavioral Health During the COVID-19 Pandemic ............................................................. 2
Mental Health ........................................................................................................... 2
Mental Health Disorders........................................................................................ 3
Suicide ............................................................................................................... 6
Substance Use........................................................................................................... 8
Substance Use-Related Overdoses .......................................................................... 8
Substance Use Disorder Services .......................................................................... 11
Differences Between Groups ..................................................................................... 12
Summary of Behavioral Health Data During the COVID-19 Pandemic ............................ 16
Changes to Behavioral Health Services During the COVID-19 Pandemic .............................. 17
Changes to Telehealth .............................................................................................. 17
Changes to Substance Use Disorder Treatment ............................................................. 18
Changes to Privacy Requirements .............................................................................. 19
HIPAA Privacy and Security Rule ......................................................................... 20
CARES Act: Harmonizing the Part 2 Rule with the HIPAA Privacy Rule .................... 23
Changes to Mental Health Parity ................................................................................ 23
Changes to Behavioral Health Funding ....................................................................... 24
Other Federal Efforts................................................................................................ 26
Issues for Congress ....................................................................................................... 27
Extending Changes to Mental Health and Substance Use Disorder Treatment ................... 27
Mental Health Effects of Stay-at-Home Orders............................................................. 29
Oversight of Funding and Federal y Supported Activities............................................... 30
Behavioral Health Disparities .................................................................................... 30

Figures
Figure 1. Mental Health Symptomology in the United States, 2019 and 2020 ........................... 5
Figure 2. Weekly Suspected Overdose Submissions.............................................................. 9
Figure 3. Drug-Related Overdose Deaths in the United States .............................................. 10
Figure 4. Mental Health Symptomology, by Household Job Loss in the United States.............. 13
Figure 5. Mental Health Symptomology, by Education Level in the United States ................... 14

Figure A-1. Mental Health Symptomology in the United States, by Income............................ 32
Figure A-2. Mental Health Symptomology in the United States over Time ............................. 33

Appendixes
Appendix. Mental Health Symptomology in the United States ............................................. 32

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Contacts
Author Information ....................................................................................................... 33

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Behavioral Health During the COVID-19 Pandemic: Overview and Issues for Congress

Introduction
Circumstances surrounding the Coronavirus Disease 2019 (COVID-19) pandemic—including
lifestyle changes instituted to prevent spread of the virus—appear to have adversely affected the
mental health of many Americans. Some studies show that Americans experienced elevated levels
of emotional distress, anxiety, depression, substance use, and drug-related overdoses in 2020 and
2021 compared with the same time periods in previous years. Various stressors related to the
pandemic may have contributed to decreased mental wel -being, such as fears about contracting
the virus, anxiety about its health effects, social isolation due to physical distancing measures,
financial stress due to the ensuing economic consequences of the pandemic, grief and
bereavement due to the death of a loved one, exposure to pandemic-related media coverage, and
interruptions to substance use treatment and mental health care.
Physical distancing measures and temporary stay-at-home orders associated with the COVID-19
pandemic have required changes in service delivery for mental health and substance use
(collectively known as behavioral health) treatment. Such changes include relaxing privacy
requirements required by the Health Insurance Portability and Accountability Act (HIPAA) rules
and increasing the use of telehealth to deliver behavioral health treatment and services. Some
states have employed other methods of service delivery (e.g., mobile units) for treatments that
cannot be administered via telehealth, such as medication-assisted treatment (MAT) for opioid
use disorder (OUD).
Congress has appropriated additional funding for behavioral health-related activities during the
pandemic through several of the COVID-19-related supplemental funding measures. The third
COVID-19 supplemental appropriations act enacted by Congress—the Coronavirus Aid, Relief,
and Economic Security (CARES) Act (P.L. 116-136)—appropriated $425 mil ion to the
Substance Abuse and Mental Health Services Administration (SAMHSA) within the Department
of Health and Human Services (HHS). The fifth COVID supplemental funding measure
(Consolidated Appropriations Act, 2021; P.L. 116-260) appropriated $4.25 bil ion to SAMHSA in
supplemental COVID-related funding.1 In March 2021, a budget reconciliation measure
developed in response to the pandemic—the American Rescue Plan Act of 2021 (ARPA; P.L.
117-2)—appropriated $3.64 bil ion to SAMHSA for behavioral health activities.2
As the COVID-19 pandemic continues, and eventual y subsides, the federal government may
consider whether to extend—or make permanent—some of the regulatory changes to behavioral
health treatment delivery. In addition, Congress and other government institutions at the federal,
state, and local level may consider the mental health consequences of COVID-related policies
such as stay-at-home orders and school reopenings. Other considerations include determining
al ocation of the pandemic-related funding and oversight of federal y supported behavioral health
activities during the pandemic and beyond.
This report provides an overview of (1) mental health and substance use during the COVID-19
pandemic, (2) changes made to behavioral health services and related regulations, and (3) issues
for Congress to consider.

1 T his amount was in addition to SAMHSA’s annual FY2021 appropriations, which were also included in the law.
2 See the House Budget Committee report (H.Rept. 117-7) for a discussion of the context surrounding the American
Rescue Plan Act of 2021 (ARPA; P.L. 117-2).
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Behavioral Health During the COVID-19 Pandemic
Data from multiple sources suggest that mental health symptoms and substance use have
increased since the beginning of the COVID-19 pandemic. These symptoms include emotional
distress and anxiety, depression, and trauma-related conditions. Substance use refers to the
number of individuals using substances such as alcohol or il icit drugs, and the frequency and
quantities of use.
Typical y, comprehensive national morbidity and mortality data on mental health conditions,
substance use, associated hospitalizations, and substance-related overdose deaths take months to
compile and report.3 Comprehensive national data for 2020 are not yet available. Several
organizations, including multiple federal agencies, have used short surveys and rapid data
reporting to monitor mental health symptoms and substance use during the COVID-19 pandemic.
Although the methodological differences between these surveys and perennial surveys make
comparisons between years imperfect, most of the 2020 data suggest an increase in behavioral
health morbidity in the United States over the course of the COVID-19 pandemic.
Mental Health
Data collected from multiple surveys during the COVID-19 pandemic suggest that Americans
experienced increased stress and symptoms of mental health conditions. In a survey conducted in
April 2020, the State Health Access Data Assistance Center (SHADAC)—a program of the
Robert Wood Johnson Foundation—found that over 90% of U.S. adults reported experiencing
additional levels of stress caused by the COVID-19 pandemic.4 In this context, stress refers to
psychological stress, which occurs when individuals believe that the consequences of a situation
outweigh their ability to adequately cope with it.5 Reactions to stressors may include fear and
concern about the future, tension and irritability, sadness or depression, or feeling powerless or
overwhelmed, among others.6
Without adequate coping strategies, stress can have detrimental effects on mental health. Coping
strategies include any behavioral, social, or cognitive techniques used to mitigate the effects of
stress. Coping strategies can be adaptive, meaning they promote better overal functioning (e.g.,
social connections, physical activities, hobbies, good sleep hygiene), or they can be maladaptive,

3 In the United States, national public health surveillance is conducted through multiple systems that typically involve
partnerships between the federal government and other jurisdictions. Morbidity and mortality data, for instance, are
collected from disparate and often private organizations, including laboratories, hospitals, and outpatient health care
facilities. T he Centers for Disease Control and Prevention (CDC) compiles and reports annual mortality data, but the
timeliness and completeness of these data are affected by a number of variables. Often, comprehensive national data for
a given year is not available until the following year. For more information, see CRS Report R46588, Tracking
COVID-19: U.S. Public Health Surveillance and Data, by Kavya Sekar and Angela Napili.
4 Colin Planalp, Giovann Alarcon, and Lynn Blewett, 90 Percent of U.S. Adults Reported Increased Stress due to the
Coronavirus Pandem ic, State Health Access Data Assistance Center (SHADAC), SHADAC COVID-19 Survey
Results, May 26, 2020, https://www.shadac.org/publications/shadac-covid-19-survey-results. T he SHADAC COVID-
19 Survey on the consequences of the coronavirus pandemic was conducted as part of the AmeriSpeak omnibus survey
conducted by NORC at the University of Chicago. T he survey was conducted using a mix of phone and online modes
from April 24 and 26, 2020, among a nationally representative sam ple of 1,007 respondents age 18 and older.
SHADAC is a partnership between the Robert Wood Johnson Foundation and the Health Policy and Management
Division of the School of Public Health at the University of Minnesota.
5 Mental Health Foundation, Stress, United Kingdom, 2021, https://www.mentalhealth.org.uk/a-to-z/s/stress.
6 Centers for Disease Control and Prevention, Injury Prevention & Control/Injury Center/Featured Topics/Dealing with
Stress, 2020, https://www.cdc.gov/injury/features/dealing-with-stress/index.html.
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Behavioral Health During the COVID-19 Pandemic: Overview and Issues for Congress

meaning they are more likely to result in worse overal functioning (e.g., substance use, excessive
screen time, risky behaviors). Although maladaptive coping strategies may reduce stress in the
moment, they may exacerbate problems in the long term.
Many individuals experiencing stress may have adequate coping strategies, meaning that stress is
present but does not impair their daily functioning.7 For others, stress—and in particular stress
caused by the pandemic—may have detrimental effects on their mental health. A national y
representative survey conducted by the Kaiser Family Foundation (KFF) throughout the
pandemic found that an increasing number of Americans reported that pandemic-related stress
was affecting their mental health.8 In March 2020, 32% of respondents felt that worry or stress
related to coronavirus had a negative impact on their mental health. In April 2020 that number
rose to 45%, and in July 2020, 53% reported that pandemic-related stress was affecting their
mental health.9
Mental Health Disorders
In some cases, extreme or prolonged stress can lead to mental health disorders.10 According to
data collected by the National Center for Health Statistics (NCHS), the percentage of Americans
experiencing symptoms of a mental health disorder appears to have increased during the COVID-
19 pandemic. NCHS—a research agency under the Centers for Disease Control and Prevention
(CDC)—partnered with the U.S. Census Bureau on the Household Pulse Survey to monitor the
social and economic effects of the pandemic on American households.11 The national y
representative survey collected data on employment status, food security, housing, physical and
mental health, access to health care (including mental health care), and education disruption
during the coronavirus pandemic.12 NCHS survey questions were designed to obtain information
on the frequency of anxiety and depression symptoms.13

7 Stress and traumatic experiences—such as those affiliated with the COVID-19 pandemic—can also lead to positive
psychological changes and improved mental health, commonly known as posttraum atic growth. See, for example,
Kristine Olson, T ait Shanafelt, and Steve Southwick, “ Pandemic-Driven Posttraumatic Growth for Organizations and
Individuals,” JAMA, vol. 324, no. 18 (October 8, 2020), pp. 1829 -1830.
8 Liz Hamel, Audrey Kearney, Ashley Kirzinger, et al., KFF Health Tracking Poll - July 2020, Kaiser Family
Foundation, July 27, 2020, https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020/.
9 See also Nirmita Panchal, Rabah Kamal, Cynthia Cox, et al., The Implications of COVID-19 for Mental Health and
Substance Use, Kaiser Family Foundation, Issue Brief, February 10, 2021, https://www.kff.org/coronavirus-covid-19/
issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.
10 See, for instance, Peggy T hoits, “Stress and Health: Major Findings and Policy Implications,” Journal of Health and
Social Behavior, vol. 51, no. 1_suppl (March 1, 2010), pp. S41 -S53; Marie-France Marin, Catherine Lord, Julie
Andrews, et al., “Chronic Stress, Cognitive Functioning and Mental Health,” Neurobiology of Learning and Memory,
vol. 96, no. 4 (November 2011), pp. 583 -595; and George P. Chrousos, “ Stress and Disorders of the Stress System,”
Nat Rev Endocrinol., vol. 5, no. 7 (July 2009), pp. 374-381.
11 U.S. Census Bureau, Measuring Household Experiences during the Coronavirus Pandemic, Household Pulse
Survey, https://www.census.gov/data/experimental-data-products/household-pulse-survey.html.
12 Phase 1 of the Household Pulse Survey was conducted from April 23 through July 21, 2020. Phase 2 was conducted
August 19 through October 26, 2020, and Phase 3 took place between October 28 and March 29, 2021. Phase 3.1 was
scheduled to begin on April 14, 2021. T he Household Pulse Survey is designed to be a short -turnaround instrument that
provides data to aid in the pandemic recovery. It is part of the Census Bureau’s Experimental Data Series, and, as such,
data products may not meet some of the Census Bureau’s typical statistical quality standards. T he experimental data
series it is designed to be timely, and therefore may have less accuracy than perennial surveys such as NHIS or the
National Survey on Drug Use and Health (NSDUH). Discretion should be used when comparing Household Pulse data
with other annual federal surveys.
13 T o capture symptoms of mental health disorders, the Household Pulse Survey used similar survey items as the annual
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As shown in Figure 1, symptoms of anxiety disorder and depressive disorder were higher in the
United States during April–June (Q2) of 2020, compared with the same period in 2019.14 More
than one in three adults experienced symptoms of anxiety, depression, or both in 2020, compared
with one in 10 in 2019.15 Subsequent data have shown that the 2020 second quarter rates
increased through the final quarter of 2020.16In February 2021, over 40% of U.S. adults had
experienced symptoms of an anxiety or a depressive disorder during the past seven days.17 Some
data from this survey suggests that as the number of COVID-19 cases has decreased national y
and pandemic-related restrictions have been lifted, symptoms of anxiety and depression have
shown modest declines (see Figure A-2).

National Health Interview Survey—but amended them to be slightly shorter. T he questions are a modified version of
the two-item PHQ-2 and GAD-2 scale on the Household Pulse Survey, collecting information on symptoms over the
past 7 days (rather than the typical 14 days). For more information, see https://www.cdc.gov/nchs/covid19/pulse/
mental-health.htm.
14 CDC, National Center for Health Statistics, Anxiety and Depression, Household Pulse Survey, 2021,
https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm.
15 Data on symptoms of anxiety and depressive disorders in the Household Pulse Survey (2020) reflect similar findings
from a single week survey conducted in June 2020. See Mark Czeisler, Rashon Lane, and Emiko Petrosky, Mental
Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandem ic - United States, June 24-30, 2020,
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), vol. 69, no. 32, Atlanta,
GA, August 14, 2020.
16 Household Pulse data show 40% of adults exhibited symptoms of one or both disorders in Q4 of 2020, compared
with 35% in Q2. More specifically, the “depression only” category increased from 4.8% to 5.1%, “anxiety only”
increased from 10.4% to 12.6%, and concurrent symptoms of both disorders increased from 20.3% to 22.7% of adults.
Some studies suggest that t he mental health effects of the pandemic may be more acute in the United States compared
with other high-income countries. An international survey showed that more U.S. adults reported experiencing stress,
anxiety, and sadness than adults in other countries during the pandemic. In addition, fewer Americans reported the
ability to receive help from a professional compared with Australia and Canada. See Reginald Williams, Arnav Shah,
Roosa T ikkanen, et al., Do Am ericans Face Greater Mental Health and Econom ic Consequences from CO VID-19?
Com paring the U.S. with Other High-Incom e Countries, T he Commonwealth Fund, Issue Brief, August 6, 2020,
https://www.commonwealthfund.org/publications/issue-briefs/2020/aug/americans-mental-health-and-economic-
consequences-COVID19.
17 Anjel Vahratian, Stephen Blumberg, Emily T erlizzi, et al., Symptoms of Anxiety or Depressive Disorder and Use of
Mental Health Care Am ong Adults During the COVID-19 Pandem ic - United States, August 2020-February 2021,
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), vol. 70, March 26,
2021.
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Behavioral Health During the COVID-19 Pandemic: Overview and Issues for Congress

Figure 1. Mental Health Symptomology in the United States, 2019 and 2020
Symptoms of Anxiety and Depression in Adults, April-June (Q2)

Source: CRS analysis of Centers for Disease Control and Prevention, 2019 NHIS, National Health Information,
https://www.cdc.gov/nchs/nhis/2019nhis.htm, and U.S. Census Bureau, Measuring Household Experiences during the
Coronavirus Pandemic, Household Pulse Survey, https://www.census.gov/data/experimental-data-products/
household-pulse-survey.html.
Notes: Estimates show the percentage of adults in the United States who reported symptoms of anxiety or
depression that have been shown to be associated with diagnoses of generalized anxiety disorder or major
depressive disorder. These symptoms general y occur more than half the days or nearly every day. The first
Household Pulse Survey was conducted starting on April 23, 2020, thus there are 22 days in the second quarter
that are missing for 2020. Along with this limitation, the two surveys differ in that the NHIS asks respondents
about the “last 2 weeks,” whereas the Household Pulse Survey asks about the “last 7 days.” See footnote 12 for
more information.
Other indicators of psychological distress appear elevated during the first phases of the pandemic.
For example, CDC analysis of national emergency department (ED) visits showed that
socioeconomic and psychosocial-related visits increased during April 2020 (compared with April
2019), while total ED visits decreased over 40%.18 Socioeconomic or psychosocial factors were
one of a few categories of ED visits that increased; most of the 200 common diagnostic causes of
ED visits decreased during that same time. Other research suggests that ED visits for mental
health conditions may have decreased during the first few months of the pandemic, to a lesser
extent than overal ED visits.19
Psychiatric Symptoms of COVID-19
In addition to the more common symptoms of COVID-19, such as upper respiratory tract infections, fever, or
acute respiratory distress, COVID-19 can also cause psychiatric symptoms.20 Research and clinical case reports
have described mental health symptoms of COVID-19 that include

18 Kathleen Hartnett, Aaron Kite-Powell, Jourdan DeVies, et al., Impact of the COVID-19 Pandemic on Emergency
Departm ent Visits - United States, January 1, 2019 - March 30, 2020, Centers for Disease Control and Prevention,
Morbidity and Mortality Weekly Report (MMWR) vol. 69, no. 23, June 12, 2020, pp. 699-704, https://www.cdc.gov/
mmwr/volumes/69/wr/mm6923e1.htm.
19 See Kristin M. Holland, Christopher Jones, Alana M. Vivolo-Kantor, et al., “T rends in US Emergency Department
Visits for Mental Health, Overdose, and Violence Outcomes Before and During the COVID -19 Pandemic,” JAMA
Psychiatry, February 3, 2021.
20 “COVID-19 and Mental Health,” Lancet Psychiatry, vol. 8 (February 2021), p. 87.
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 anxiety21 and depression;
 altered mental status (e.g., confusion, delirium, agitation);
 psychosis (e.g., delusions, hal ucinations, paranoia);
 post-traumatic stress;
 impaired memory; and
 insomnia.22
Most individuals diagnosed with COVID-19 do not experience any mental health issues. However, for some
(especial y those with severe COVID-19 infections), psychiatric symptoms can appear during the acute il ness or
post-il ness stages.23 The causes of psychiatric symptoms of COVID-19 are unclear.24 Some research suggests that
the infection can have possible neurological effects and cause inflammation of the brain.25 In addition, the
experience of having COVID-19 may lead to altered mood, post-traumatic stress, or other mental health
symptoms.26 Studies report worsening of symptoms for COVID-19 patients with preexisting psychiatric disorders,
though individuals with no history of mental il ness have also displayed psychiatric symptoms during and after the
il ness.27 An international study fol owing 284 patients found that over a third (34.5%) reported clinical y significant
post-traumatic stress symptoms, anxiety, and/or depression nearly two months after a COVID-19 diagnosis.28 The
presence of psychiatric symptoms during COVID-19 is consistent with prior research on other coronavirus
infections, which found that confusion, impaired memory, depressed mood, anxiety, and insomnia are common
symptoms.29
Suicide
Some evidence suggests that suicidal thoughts may have increased during the pandemic. One
CDC analysis found that during the pandemic approximately twice as many U.S. adults reported
serious consideration of suicide in the previous 30 days compared with 2018 (10.7% versus

21 Of note, CDC has reported some anxiety-related adverse events associated with COVID-19 vaccinations. See Anne
M. Hause, Julianne Gee, T ara Johnson, et al., Anxiety-Related Adverse Event Clusters After Janssen COVID-19
Vaccination - Five U.S. Mass Vaccination Sites, April 2021 , Centers for Disease Control and Prevention, Morbidity and
Mortality Weekly Report (MMWR) vol. 70, no. 18, May 7, 2021, pp. 685 -688, https://www.cdc.gov/mmwr/volumes/70/
wr/mm7018e3.htm.
22 See, for example, Maxime T aquet, John R. Geddes, Masud Husain, et al., “6-Month Neurological and Psychiatric
Outcomes in 236,379 Survivors of COVID-19: A Retrospective Cohort Study Using Electronic Health Records,” The
Lancet Psychiatry, vol. 8, no. 5 (May 1, 2021), pp. 416 -427; and Aravinthan Varatharaj, Naomi T homas, and Mark A.
Ellul, “Neurological and Neuropsychiatric Complications of COVID-19 in 153 Patients: A UK-Wide Surveillance
Study,” The Lancet Psychiatry, vol. 7, no. 10 (October 1, 2020), pp. 875-882.
23 Jonathan P. Rogers, Edward Chesney, Dominic Oliver, et al., “Psychiatric and Neuropsychiatric Presentations
Associated with Severe Coronavirus Infections: A Systematic Review and Meta -analysis with Comparison to the
COVID-19 Pandemic,” The Lancet Psychiatry, vol. 7, no. 7 (July 2020), pp. 611-627.
24 S. Al-Sarraj, C. T roakes, B. Hanley, et al., “Invited Review: T he Spectrum of Neuropathology in COVID -19,”
Neuropathology and Applied Neurobiology, vol. 47 (2021), pp. 3-16.
25 Krishna Nalleballe, Sanjeeva Reddy Onteddu, Rohan Sharma, et al., “Spectrum of Neuropsychiatric Manifestations
in COVID-19,” Brain, Behavior, and Im m unity, vol. 88 (August 2020), pp. 71-74; and Jakob Matschke, Marc
Lutgehetmann, Christian Hagel, et al., “Neuropathy of Patients with COVID-19 in Germany: A Post-Mortem Case
Series,” The Lancet Neurology, vol. 19, no. 11 (November 1, 2020), pp. 919-929.
26 Burc Cagri Poyraz, Cana Aksoy Poyraz, and Yesim Olgun, “Psychiatric Morbidity and Protracted Symptoms After
COVID-19,” Psychiatric Research, vol. 295 (January 2021).
27 Nina Vindegaard and Michael Eriksen Benros, “COVID-19 Pandemic and Mental Health Consequences: Systematic
Review of the Current Evidence,” Brain, Behavior, and Immunity, vol. 89 (October 2020), pp. 531-542.
28 Poyraz et al., “Psychiatric Morbidity and Protracted Symptoms After COVID-19,” 2021.
29 Rogers et al., “Psychiatric and Neuropsychiatric Presentations Associated with Severe Coronavirus Infections,”
2020.
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4.3%).30 Although the National Suicide Prevention Lifeline did not report increases in cal
volume, the Disaster Distress Helpline (part of the Suicide Lifeline) experienced a 335% increase
in cal s during the first five months of the pandemic.31
The effects of the pandemic on suicide attempts and suicide deaths is unclear, though it appears
that suicide mortality has decreased compared with previous years. An increase in suicidal
thoughts does not necessarily equate to an increase in suicide attempts or suicide deaths.32
Research from CDC shows a decrease in emergency department (ED) visits for suicide attempts
between March and October 2020 compared with the same period in 2019, but to a lesser extent
than overal ED visits.33 Preliminary national suicide mortality data in the United States for 2020
show that suicide deaths in the United States may have decreased in 2020 compared with the
three previous years.34 In addition, regional differences may account for changes in suicide
mortality. For example, some individual states and municipalities have reported stable rates in
suicide deaths during the pandemic, whereas others have reported decreased rates.35 There may be
demographic differences in suicide rates during the pandemic also. For example, CDC reported
that in May, 2020 ED visits for suspected suicide attempts began to increase among adolescents,
especial y girls.36 Researchers in Maryland found that suicide mortality rates increased for Black
residents from March, 2020 to May, 2020, while decreasing for White residents over that same
time.37

30 Mark Czeisler, Rashon Lane, and Emiko Petrosky, Mental Health, Substance Use, and Suicidal Ideation During the
COVID-19 Pandem ic - United States, June 24-30, 2020, Centers for Disease Control and Prevention, Morbidity and
Mortality Weekly Report (MMWR), vol. 69, no. 32, Atlanta, GA, August 14, 2020. Data were from the Household Pulse
Survey. Researchers did not compare 2020 suicidal ideation data to 2019 data, nor did they explain their choice of 2018
as the comparison year.
31 Communications Daily, “Some Disaster Distress Helpline Call T raffic Jumps During COVID-19,” emailed press
release, September 3, 2020, and Vibrant Emotional Health, “Help When it’s Needed Most: T he National Disaster
Distress Hotline,” press release, August 26, 2020, https://www.vibrant.org/stories-from-the-disaster-distress-helpline/.
32 For further discussion on suicide during the COVID-19 pandemic, see Christine Moutier, “Suicide Prevention in the
COVID-19 Era: T ransforming T hreat into Opportunity,” JAMA Psychiatry, vol. 78, no. 4 (October 16, 2020), pp. 433 -
438.
33 Kristin M. Holland, Christopher Jones, Alana Vivolo-Kantor, et al., “T rends in US Emergency Department Visits for
Mental Health, Overdose, and Violence Outcomes Before and During the COVID-19 Pandemic,” JAMA Psychiatry,
February 3, 2021.
34 Farida B. Ahmad and Robert N. Anderson, “T he Leading Causes of Death in the U.S. for 2020,” JAMA, March 31,
2021, https://jamanetwork.com/journals/jama/fullarticle/2778234.
35 Reports from some individual states—such as Massachusetts and Utah, for example—suggest that suicide death rates
during the pandemic may be stable compared with previous years. See Jeremy Samuel Faust, Sejal Shah, Chengan Du,
et al., “Suicide Deaths During the COVID-19 Stay-at-Home Advisory in Massachusetts, March to May 2020,” JAMA
Network Open, vol. 4, no. 1 (January 21, 2021); and Utah Department of Health, Social and Behavioral Health During
COVID-19, February 2021, https://coronavirus-download.utah.gov/Health/COVID_Mental_Health_Report_.pdf. Other
locations have reported decreases. See, for example, Jesse Bogan, “ Fewer People Are Dying by Suicide in St. Louis
During Pandemic,” St. Louis Post-Dispatch, October 29, 2020, https://www.stltoday.com/news/local/metro/fewer-
people-are-dying-by-suicide-in-st-louis-during-pandemic/article_b4200ed7-4d00-5645-b7b7-961f4fb76c64.html.
36 Ellen Yard, Lakshmi Radhakrishnan, and Michael Ballesteros, et al., Emergency Department Visits for Suspected
Suicide Attempts Among Persons Aged 12–25 Years Before and During the COVID-19 Pandemic—United States,
January 2019–May 2021, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, vol.,
70, Atlanta, GA, June 11, 2021, https://www.cdc.gov/mmwr/volumes/70/wr/mm7024e1.htm?s_cid=mm7024e1_w.
Additionally, CDC reported that suspected suicide attempt ED visits were 50.6% higher among girls aged 12–17 years
during February 21–March 20, 2021 compared to the same period in 2019.
37 Michael Johnathan Charles Bray, Nicholas Omid Daneshvari, and Indu Radhakrishnan, et al., “Racial Differences in
Statewide Suicide Mortality T rends in Maryland During the Coronavirus Disease 2019 (COVID-19) Pandemic,” JAMA
Psychiatry, vol. 78, no. 4 (December 16, 2020). Suicide mortality rates for Black residents from May, 2020 to July,
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Substance Use
Substance use rates appear to have increased during the COVID-19 pandemic. Certain
consequences of the pandemic—such as increased stress and prolonged social isolation—have
been linked with increased vulnerability to alcohol and drug use.38 During the pandemic, Nora
Volkow—Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of
Health (NIH)—stated:
All of these aspects [of the pandemic] are translating into much more stress. And stress, as
we know, is one of the factors that leads people to relapse. Stress is also a factor that leads
many to increase consumption of drugs.39
In reporting data from the Household Pulse Survey, CDC indicated that 13% of U.S. adults
started or increased substance use in the first few months of the pandemic to cope with stress
related to COVID-19.40 Increased substance use can lead to the development or exacerbation of
substance use disorders, increased health conditions, or premature death.41 In addition, COVID-
19 mitigation measures might lead persons using opioids or other substances to do so in higher-
risk ways, such as alone or without access to overdose reversal medications such as naloxone.
Substance Use-Related Overdoses
Comprehensive national data on drug-related overdoses and overdose deaths during the pandemic
are not yet available. Preliminary data from the Office of National Drug Control Policy (ONDCP)
suggest increases in drug-related overdoses during the first few months of the pandemic. The
Overdose Detection Mapping Application Program (ODMAP), an ONDCP surveil ance system
that tracks suspected overdose data national y in near real-time, reported an increase of 11% in
fatal overdoses and a 19% increase in nonfatal overdoses from March through May 2020
compared with the same months in 2019.42 Nearly 62% of participating counties reported
increases from March to May 2020.43 Other areas have reported stable rates of overdose deaths.44
Notably, ODMAP overdose submissions appeared to be trending upward prior to the onset of the
pandemic, making it difficult to determine the effects of the pandemic and mitigation measures

2020 remained higher than their pre-pandemic levels, while rates continued to decrease for White Maryland residents
during that same time period.
38 Primavera Spagnolo, Chiara Montemitro, and Lorenzo Leggio, “New Challenges in Addiction Medicine: COVID -10
Infection in Patients with Alcohol and Substance Use Disorders—T he Perfect Storm,” The Am erican Journal of
Psychiatry, July 14, 2020.
39 Francis Collins, Nora Volkow - Addressing the Twin Challenges of Substance Use Disorders and COVID-19,
National Institutes of Health, NIH Director’s Blog, August 11, 2020, https://directorsblog.nih.gov/tag/nora-volkow/.
40 Czeisler et al., Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic—United
States, June 24–30, 2020. For this survey, substance use was defined as use of “ alcohol, legal or illegal drugs, or
prescriptions drugs that are taken in a way not recommended by your doctor.”
41 See, for instance, Marya T . Schulte and Yih-Ing Hser, “Substance Use and Associated Health Conditions T hroughout
the Lifespan,” Public Health Reviews, vol. 35, no. 2 (2013).
42 Aliese Alter and Christopher Yeager, The Consequences of COVID-19 on the Overdose Epidemic: Overdoses are
Increasing, ODMAP Overdose Detection Mapping Application Program, ODMAP Report, May 2020,
http://odmap.org/Content/docs/news/2020/ODMAP-Report-May-2020.pdf; and Aliese Alter and Christopher Yeager,
COVID-19 Im pact on US National Overdose Crisis, ODMAP Overdose Detection Mapping Application Program,
ODMAP Report, June 2020, http://www.odmap.org/Content/docs/news/2020/ODMAP -Report-June-2020.pdf.
43 Alter and Yeager, The Consequences of COVID-19 on the Overdose Epidemic, 2021.
44 Utah, for instance, reported no significant change in drug-related overdose deaths from 2019 through 2020. See Utah
Department of Health, Social and Behavioral Health During COVID-19, January 2021, https://coronavirus-
download.utah.gov/Health/COVID_Mental_Health_Report_.pdf.
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using these data. Figure 2 shows weekly ODMAP-suspected overdose submissions for the first
few months of 2020.
Figure 2. Weekly Suspected Overdose Submissions
ODMAP Submissions January 1, 2020, to March 18, 2020 Compared with March 19, 2020 to May 19,
2020

Source: Aliese Alter and Christopher Yeager, COVID-19 Impact on US National Overdose Crisis, ODMAP
Overdose Detection Mapping Application Program, ODMAP Report, June 2020, http://www.odmap.org/Content/
docs/news/2020/ODMAP-Report-June-2020.pdf.
Notes: For the purposes of its analysis, ODMAP considered the pre-stay-at-home period as January 1, 2020,
through March 18, 2020, and the post-stay-at-home period as March 19, 2020, through May 19, 2020.
Implementation date of mandated stay-at-home orders varied by state. Most states instituted mandated orders
between March 19, 2020 and April 3, 2020.
CDC also noted an increase in drug-related overdose deaths in the beginning of the COVID-19
pandemic.45 Similar to the ODMAP data, the CDC data showed that overdose deaths were already
increasing in the months preceding the pandemic. However, CDC data showed the rate of
overdose deaths accelerating after the pandemic began (see Figure 3).46 In an analysis of
provisional CDC mortality data, the National Institute for Health Care Management47 found that

45 Centers for Disease Control and Prevention, “Overdose Deaths Accelerating During COVID-19,” press release,
December 18, 2020, https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html.
46 Centers for Disease Control and Prevention, National Center for Health Statistics, Provisional Drug Overdose Death
Counts, Vital Statistics Rapid Release, 2021, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. T hese CDC
data reflect similar findings from drug overdose data on the local level for some states and municipalities. For example,
in Cook County, Illinois, opioid-related overdose deaths were increasing prior to the pandemic, but showed a more
pronounced increase during the 11-week stay-at-home orders. See Maryann Mason, Ponni Arukumar, and Joe
Feinglass, “T he Pandemic Stay-at-Home Order and Opioid Involved Overdose Fatalities,” JAMA Insights, vol. 325, no.
24 (April 23, 2021), pp. 2495-2496.
47 T he National Institute for Health Care Management (NIHCM) Foundation is a nongovernmental, nonpartisan
organization “dedicated to transforming health care through evidence and collaboration.” T he NIHCM Foundation
frequently publishes data reports and infographics using federal data sources such as CDC mortality data. More
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the rise is particularly notable for deaths involving synthetic opioids. In addition, the institute
reported increases in deaths involving commonly prescribed opioids and heroin—both of which
had been declining in recent years.48
Figure 3. Drug-Related Overdose Deaths in the United States
January 2015–September 2020

Source: CRS analysis of data from Centers for Disease Control and Prevention, National Center for Health
Statistics, Provisional Drug Overdose Death Counts, Vital Statistics Rapid Release, 2021, https://www.cdc.gov/nchs/
nvss/vsrr/drug-overdose-data.htm.
When examining emergency department (ED) visits, CDC found a higher number of drug
overdoses—including opioid overdoses—between March and October 2020 compared with the
same period in 2019.49 Put together, the ODMAP and CDC data suggest that drug-related
overdoses and overdose deaths have increased during the COVID-19 pandemic.
Individuals with substance use disorders may be at higher risk of contracting SARS-CoV-2 due to
unstable housing situations, high incarceration rates, or the inability to physical y distance
themselves.50 In addition, those with substance use disorders may be at higher risk for
complications of COVID-19 because substance use can often suppress the immune system or
inhibit respiratory functioning.51

information is available at https://nihcm.org/about-us.
48 National Institute for Health Care Management (NIHCM) Foundation, Synthetic Opioid Driving a Worsening Crisis
of Overdose Deaths, Infographics, Washington, DC, April 2, 2021, https://nihcm.org/publications/synthetic-opioids-
driving-a-worsening-crisis-of-overdose-deaths.
49 Holland et al., “T rends in US Emergency Department Visits,” 2021.
50 SARS-CoV-2 is the name for the coronavirus that causes coronavirus disease (COVID-19). QuanQiu Wang, Rong
Xu, and Nora D. Volkow, “Increased Risk of COVID-19 Infection and Mortality in People with Mental Disorders:
Analysis from Electronic Health Records in the United States,” World Psychiatry, vol. 20, no. 1 (February 2021); and
Osnat Melamed, T anya Hauck, Leslie Buckley, et al., “COVID-19 and Persons with Substance Use Disorders:
Inequities and Mitigation Strategies,” Substance Abuse, vol. 41, no. 3 (July 22, 2020), pp. 286-291.
51 Quan Qui Wang, David Kaelber, and Rong Xu, “COVID Risks and Outcomes in Patients with Substance Use
Disorders: Analyses from Electronic Health Records in the United States,” Molecular Psychiatry, vol. 26 (September
14, 2020), pp. 30-39; and Jacques Baillargeon, Efstathaia Polychronopoulou, Yong-Fang Kuo, et al., “ T he Impact of
Substance Use Disorder on COVID-19 Outcomes,” Psychiatry Online, November 3, 2020.
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Substance Use Disorder Services
Pandemic-related physical distancing measures may prevent individuals in need of substance use
disorder treatment from accessing services. Lack of access to effective treatment may lead to
relapse and increase the risk of overdose and death. During the pandemic, many harm reduction
and overdose prevention and response activities have been suspended or are operating at a
reduced capacity.52
Substance use disorder treatment services involving physical interactions have been most affected
by the pandemic. For example, it has been difficult for individuals to access peer-led programs
such as Alcoholics Anonymous and Narcotics Anonymous.53 These programs provide individuals
with substance use disorders with certain supports—such as mentoring and a social support
system—that are considered fundamental for recovery.54 The National Association of County and
City Health Officials (NACCHO) identified the following disruptions to overdose prevention
services:
 reduced harm reduction programs, such as syringe service programs;
 greater difficulties connecting to individuals who have experienced overdose,
including through peer recovery specialist programs and warm handoffs in the
emergency department;
 chal enges sharing best practices information with providers and disseminating
provider education;
 barriers to accessing medication-assisted treatment; and
 complications in overdose prevention messaging.55
A National Council for Behavioral Health survey of 3,400 behavioral health provider
organizations reported that although 52% of facilities reported an increase in demand for services
during the first six months of the pandemic, over 54% had cut back their programs.56 In a follow-
up survey in January 2021, 45% of organizations reported closing programs due to COVID-19,
while the percentage reporting a demand for services increased to 67%.57
While the use of telehealth services has increased throughout the pandemic, an analysis by the
Commonwealth Fund showed that weekly visits to behavioral health providers remain below their
baseline prepandemic levels.58 Although certain services can be effectively provided through

52 National Association of County and City Health Officials (NACCHO), “Report from the Field: COVID -19 Impact
on Overdose Response Activities at Local Health Departments,” press release, August 3, 2020,
https://www.naccho.org/blog/articles/press-release-report -from-the-field-covid-19-impact-on-overdose-response-
activities-at-local-health-departments.
53 Collins, Nora Volkow - Addressing the Twin Challenges of Substance Use Disorders and COVID-19, 2020.
54 Ibid.
55 NACCHO, “Report from the Field: COVID-19 Impact on Overdose Response Activities at Local Health
Departments,” 2020.
56 National Council for Behavioral Health, Member Survey, National Council for Behavioral Health Polling
Presentation, Washington, DC, September 2020, https://www.thenationalcouncil.org/wp-content/uploads/2020/09/
NCBH_Member_Survey_Sept_2020_CT D2.pdf.
57 National Council for Behavioral Health, Member Survey, National Council for Behavioral Health Polling
Presentation, Washington, DC, February 2021, https://www.thenationalcouncil.org/wp-content/uploads/2021/03/
NCBH-Member-Survey-Feb-2021.pdf.
58 https://www.commonwealthfund.org/publications/2020/oct/impact-covid-19-pandemic-outpatient-care-visits-return-
prepandemic-levels.
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virtual telehealth platforms, some patients and providers have questioned whether virtual sessions
can impart the same benefits of in-person services—particularly group therapy and peer-led
programs.59 Moreover, scientific research on telehealth is nascent, and questions remain regarding
the effectiveness of telehealth modalities for certain populations and mental health conditions.60
In April 2021, Government Accountability Office (GAO) published a report on the effects of the
COVID-19 pandemic on patient access to behavioral health services. GAO found that long-
standing unmet needs for behavioral health services persisted and were often worsened by new
chal enges associated with the pandemic.61
Differences Between Groups
Certain groups appear to be disproportionately affected by increases in behavioral health issues
associated with the COVID-19 pandemic. The 2020 Household Pulse data showed differences in
symptoms of anxiety and depression by education level, income level, age, ethnicity, and
household job loss. For example, 45% of individuals in a household that experienced job loss had
symptoms of anxiety or depressive disorder compared with 27% of those in households without
job loss (Figure 4).62 Mental health symptoms appear particularly stratified by education level
and income. For instance, 44% of individuals with less than a high school education exhibited
symptoms of an anxiety or depressive disorder compared with 29% of individuals with a
bachelor’s degree or higher (Figure 5). Over 50% of individuals making less than $25,000
annual y exhibited symptoms of one or both mental health conditions compared with 35% of
those making $50,000-$75,000 and 23% of those with an income above $150,000 (Figure A-1).

59 Haim Weinberg, “Online Group Psychotherapy: Challenges and Possibilities During COVID-19—A Practice
Review,” Group Dynamics: Theory, Research, and Practice, vol. 24, no. 3 (2020), pp. 201-211.
60 See, for example, David Hailey, Risto Roine, and Arto Ohinmaa, “T he Effectiveness of T elemental Health
Applications: A Review,” The Canadian Journal of Psychiatry, November 1, 2008; and Donald M. Hilty, Daphne C.
Ferrer, Michele Burke Parish, et al., “T he Effectiveness of T elemental Health: A 2013 Review,” Telemedicine Journal
and e-Health, vol. 19, no. 6 (2013), pp. 444-454..
61 U.S. Government Accountability Office, Behavioral Health: Patient Access, Provider Claims Payment, and the
Effects of the COVID-19 Pandem ic, GAO-21-437R, April 30, 2021, https://www.gao.gov/products/gao-21-437r.
62 Findings from the December KFF Health T racking Poll also indicated that households experiencing income or job
loss were significantly more likely to report that worry or stress over the coronavirus outbreak has negatively affected
their mental health (KFF 2021).
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Figure 4. Mental Health Symptomology, by Household Job Loss in the United States
Symptoms of Anxiety and Depression, April 2020–June 2020

Source: CRS Analysis of U.S. Census Bureau, Measuring Household Experiences during the Coronavirus Pandemic,
Household Pulse Survey, https://www.census.gov/data/experimental-data-products/household-pulse-survey.html.
Notes: Estimates show the percentage of adults who reported symptoms of anxiety or depression that have
been shown to be associated with diagnoses of generalized anxiety disorder or major depressive disorder. These
symptoms general y occur more than half the days or nearly every day. Percentages may not add to totals due to
rounding.
Another CDC survey conducted in June 2020 reflected similar mental health differences by age,
caregiver status, and employment status and type. For example, at least one adverse mental or
behavioral health symptom was reported by more than half of respondents who were aged 18–24
(74.9%) and 25–44 (51.9%), as wel as those who were essential workers (54.0%) or unpaid
caregivers for adults (66.6%).63 In this survey, the percentage of respondents who reported having
seriously considered suicide in the past 30 days (10.7%) was significantly higher among
respondents aged 18–24 (25.5%), certain minority racial/ethnic groups, unpaid caregivers for
adults (30.7%), and essential workers (21.7%).64

63 Mark Czeisler, Rashon Lane, and Emiko Petrosky, Mental Health, Substance Use, and Suicidal Ideation During the
COVID-19 Pandem ic—United States, June 24-30, 2020, Centers for Disease Control and Prevention, Morbidity and
Mortality Weekly Report (MMWR), vol. 69, no. 32, Atlanta, GA, August 14, 2020.
64 Ibid. Prevalence decreased progressively with age.
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Figure 5. Mental Health Symptomology, by Education Level in the United States
Symptoms of Anxiety and Depression, April 2020 – June 2020

Source: CRS analysis from U.S. Census Bureau, Measuring Household Experiences during the Coronavirus Pandemic,
Household Pulse Survey, https://www.census.gov/data/experimental-data-products/household-pulse-survey.html.
Notes: Estimates show the percentage of adults who reported symptoms of anxiety or depression that have
been shown to be associated with diagnoses of generalized anxiety disorder or major depressive disorder. These
symptoms general y occur more than half the days or nearly every day. Percentages may not add to totals due to
rounding.
Overal , data from CDC has indicated that mental health symptoms associated with the early
phases of the COVID-19 pandemic may have disproportionately affected those who are
 young adults (aged 18-24),
 Black or Latino/Hispanic,
 essential workers,
 unpaid caregivers for adults,
 unemployed,
 individuals with low income levels, or
 individuals with less than high school diploma.65

65 Mark Czeisler, Rashon Lane, and Emiko Petrosky, Mental Health, Substance Use, and Suicidal Ideation During the
COVID-19 Pandem ic—United States, June 24-30, 2020, Centers for Disease Control and Prevention, Morbidity and
Mortality Weekly Report (MMWR), vol. 69, no. 32, Atlanta, GA, August 14, 2020; and Lela R. McKnight -Eily,
Catherine A. Okoro, and T ara W. Strine, Racial and Ethnic Disparities in the Prevalance of Stress and Worry, Mental
Health Conditions, and Increased Substance Use Am ong Adults During the COVID -19 Pandem ic - United States, April
and May 2020, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), vol. 70,
no. 5, February 5, 2021, pp. 162-166, https://www.cdc.gov/mmwr/volumes/70/wr/mm7005a3.htm. See Figure A-1.
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The disproportionate stress—and subsequence behavioral health issues—for some groups could
be influenced by several factors.
The economic consequences of the pandemic have resulted in significant financial strain for
many individuals. The KFF July 2020 Health Tracking Poll revealed that of the people who
indicated that pandemic-related stress had caused adverse effects on their mental health, 75%
reported difficulties affording household expenses. This correlation between financial strain and
mental health differed between groups. For example, roughly 7 in 10 Black adults and individuals
who had difficulty paying household bil s in the past three months due to the financial impact of
the coronavirus said that stress and worry related to the pandemic had a negative impact on their
mental health.66
Fears of contracting the virus, especial y for those at high risk, could increase stress and
symptoms of anxiety and depression. Essential workers, for instance, are general y required to
work outside of their home and may be unable to practice physical distancing. Consequently, they
are at increased risk of contracting coronavirus and exposing other members of their household to
it.67 According to a KFF June 2020 analysis, essential workers were more likely than nonessential
workers to report symptoms of anxiety or depressive disorder (42% vs. 30%, respectively), to
start or increase substance use (25% vs. 11%), or to consider suicide in the past 30 days (22% vs.
8%).68
Other factors contribute to the differences in behavioral health issues between groups, such as the
amount of COVID-19-related stressors experienced and access to effective resources for coping
with pandemic-related stress. For example, one study found that U.S. adults who experienced
more COVID-19-related stressors than other adults had a greater incidence of depressive
symptoms.69 Additional y, groups differ in their use of adaptive and maladaptive coping
strategies. The SHADAC survey found variations in coping responses by age, sex, education,
health status, and income.70 Groups with higher risks for pandemic-related stressors also reported
coping responses associated with greater health risks. The survey found higher alcohol
consumption among younger adults, more unhealthy eating habits among women, and higher
tobacco use among individuals with less education. Conversely, people with higher incomes were
more likely to report healthier coping strategies, such as increased exercise. Such variations can
compound behavioral health disparities among groups, in that groups with fewer stressors may
employ healthy coping strategies, whereas groups at higher risk for pandemic-related mental
health symptoms may use coping mechanisms that further jeopardize their health.

66 Liz Hamel, Audrey Kearney, Ashley Kirzinger, et al., KFF Health Tracking Poll - July 2020, Kaiser Family
Foundation, July 27, 2020, https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020/.
67 Nirmita Panchal, Rabah Kamal, Cynthia Cox, et al., The Implications of COVID-19 for Mental Health and Substance
Use, Kaiser Family Foundation, Issue Brief, February 10, 2021, https://www.kff.org/coronavirus-covid-19/issue-brief/
the-implications-of-covid-19-for-mental-health-and-substance-use/.
68 Ibid., and Czeisler et al., Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic—
United States, June 24–30, 2020.
69 Catherine Ettman, Salma Abdalla, Gregory Cohen, et al., “Prevalence of Depression Symptoms in U S Adults Before
and During the COVID-19 Pandemic,” JAMA Network Open, vol. 3, no. 9 (September 2, 2020).
70 Planalp et al., 90 Percent of U.S. Adults Reported Increased Stress due to the Coronavirus Pandemic, 2020.
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Summary of Behavioral Health Data During the COVID-19
Pandemic
Data from multiple sources suggest that mental health issues and substance use rates have
increased during the COVID-19 pandemic. A greater number of Americans are experiencing
stress and symptoms of mental health conditions than in previous years. Mental health conditions
are disproportionately affecting specific populations, especial y young adults, Black and Hispanic
persons, essential workers, unpaid caregivers for adults, and households that have experienced
job loss, among others.
Substance use rates appear to have increased during the COVID-19 pandemic. More than 1 in 10
adults started or increased substance use to cope with stress related to COVID-19. National drug-
related overdose data remain limited, and some overdose metrics—such as emergency department
visits and ODMAP-suspected overdose submissions—appeared to be increasing before the
COVID-19 pandemic.71 As a result, determining the effects of the pandemic and related
mitigation efforts on drug-related overdose rates is difficult. Regardless of the underlying causes,
the data suggest that substance use rates and drug-related overdoses increased during the
pandemic in 2020.
For individuals in need of mental health or substance use disorder treatment, pandemic-related
physical distancing measures may have made it difficult to access such services. An estimated
10%-20% of individuals in need of mental health services during the pandemic did not receive
them.72
The behavioral health consequences of the COVID-19 pandemic may extend beyond the public
health emergency itself. Many individuals experiencing pandemic-related stress may readjust
when the event is over, while others may be left with mental health conditions and substance use
disorders that outlast the pandemic.73 Substance use disorders and mental health conditions
spurred by the pandemic could have lasting effects on morbidity and mortality. A projected
analysis by the Wel being Trust estimated that the pandemic could influence between 27,644 and
154,037 additional behavioral health-related deaths over the next decade.74

71 National Center for Health Statistics, Provisional Drug Overdose Death Counts, Vital Statistics Rapid Release,
Hyattsville, MD, 2021, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
72 Vahratian et al., Sympt oms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During
the COVID-19 Pandemic, 2021; and Kaiser Family Foundation, Unmet Need for Counseling or T herapy Among
Adults Reporting Symptoms of Anxiety and/or Depressive Disorder During the COVID-19 Pandemic, State Health
Facts, February 2021, https://www.kff.org/other/state-indicator/unmet-need-for-counseling-or-therapy-among-adults-
reporting-symptoms-of-anxiety-and-or-depressive-disorder-during-the-covid-19-pandemic/?currentTimeframe=0&
sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
73 Antonis Kousoulis, T ine Van Bortel, Priscila Hernandez, et al., The Long Term Mental Health Impact of COVID-19
Must Not Be Ignored, BMJ, T he BMJ Opinion, May 5, 2021, https://blogs.bmj.com/bmj/2020/05/05/the-long-term-
mental-health-impact-of-covid-19-must-not-be-ignored/.
74 Stephen Petterson, John M. Westfall, and Benjamin F. Miller, Projected Deaths of Despair from COVID-19, Well
Being T rust, May 8, 2020, https://wellbeingtrust.org/wp-content/uploads/2020/05/WBT_Deaths-of-Despair_COVID-
19-FINAL-FINAL.pdf.
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Changes to Behavioral Health Services During the
COVID-19 Pandemic
Except for during the COVID-19 pandemic, most mental health treatment is typical y
administered in outpatient settings where patients visit providers in brick-and-mortar offices,
clinics, hospitals, or specialty facilities. Treatment visits may occur on a regular basis (e.g.,
weekly, monthly); as a single, one-time visit (such as for an evaluation); or in discrete episodes as
full-day or overnight visits as part of more intensive service like intensive outpatient, residential,
or partial hospitalization programs. As technology has advanced, some behavioral health
treatment providers have used telehealth (or telemedicine) modalities such as video conferencing
to deliver services. Behavioral health services via telehealth (known as telebehavioral health) are
provided through live video and mobile telephone cal s or applications.
Substance use disorder treatment works similarly in most instances, with exceptions for
interventions using frequent administration of medications, such as medication-assisted treatment
(MAT) for opioid use disorder (OUD).75 For MAT that uses opioid agonist treatments such as
methadone and buprenorphine, patients are required by law to attend in person for at least the
initial visit for buprenorphine, and daily for methadone.76 Methadone is administered on a daily
basis in federal y certified opioid treatment programs (OTPs; also known as methadone clinics),
with some short-term take-home doses al owed for stable patients.77
Physical distancing measures and temporary stay-at-home orders associated with the COVID-19
pandemic have required changes in service delivery for mental health and substance use
treatment. Such changes include relaxing privacy requirements required by the Health Insurance
Portability and Accountability Act (HIPAA) rules and increasing the use of telehealth to deliver
behavioral health treatment and services. In addition, some states have employed other methods
of service delivery (e.g., mobile units) for treatments that cannot be administered via telehealth,
such as MAT for OUD.
Changes to Telehealth
On March 13, 2020, the HHS Secretary implemented the Section 1135 waiver authority from the
Social Security Act in an effort to ensure that sufficient health care services are available to
individuals enrolled in Medicare, Medicaid and Children’s Health Insurance Program (CHIP).78
Using this new authority, which was authorized by the Coronavirus Preparedness and Response
Supplemental Appropriations Act, 2020 (P.L. 116-123), and other COVID-19 related acts, the
HHS Secretary waived or modified telebehavioral health-related participation requirements under

75 CRS In Focus IF10219, Opioid Treatment Programs and Related Federal Regulations.
76 CRS Report R45279, Buprenorphine and the Opioid Crisis: A Primer for Congress.
77 Drug Enforcement Administration, Use of Telemedicine While Providing Medication Assisted Treatment (MAT),
Diversion Control, May 15, 2018, https://www.samhsa.gov/sites/default/files/programs_campaigns/
medication_assisted/telemedicine-dea-guidance.pdf.
78 Alex Azar II, Secretary of Health and Human Services, Waiver or Modification of Requirements Under Section 1135
of the Social Security Act, U.S. Department of Health and Human Services, Office of the Assistant Secretary for
Preparedness and Response, March 13, 2020, https://www.phe.gov/emergency/news/healthactions/section1135/Pages/
covid19-13March20.aspx. For more information, see CRS Legal Sidebar LSB10430, Section 1135 Waivers and
COVID-19: An Overview.
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programs administered by the Centers for Medicare & Medicaid Services (CMS).79 For instance,
CMS announced that it would now reimburse for audio-only behavioral health telephone visits.
Other federal agencies have also addressed telebehavioral health services relative to their
missions. For example, the Health Resources and Services Administration (HRSA) of HHS
continued to administer demonstration programs aimed at assessing whether telehealth networks
can improve access to behavioral health in rural and frontier communities under the Substance
Abuse Treatment Network Grant Program and Evidence-Based Tele-Behavioral Health Network
Grant Program.80 The Department of Veterans Affairs expanded telebehavioral health care
services to veterans by entering into short-term agreements with telecommunications companies
and through mobile applications such as COVID Coach and Mindfulness Coach.81
In conjunction with the federal government, some states have waived or modified laws and
reimbursement policies on telebehavioral health during the COVID-19 pandemic.82 Since the
pandemic began, behavioral health service providers have substantial y increased the use of
telehealth.83 However, the increase in telehealth use does not appear to have offset clinic closures
or other reductions to treatment service capacity enough to adequately meet the demand for
services during the pandemic.84 A KFF poll found that nearly a quarter of adults with symptoms
of anxiety or depressive disorders reported an unmet need for counseling or therapy throughout
the pandemic.85
Changes to Substance Use Disorder Treatment
The Controlled Substances Act includes limits on prescribing controlled substances over the
internet.86 For example, patients initiating MAT with buprenorphine for opioid use disorder

79 Centers for Medicare and Medicaid Services, “T rump Administration Issues Second Round of Sweeping Changes to
Support U.S. Healthcare System During COVID-19 Pandemic,” press release, April 30, 2020, https://www.cms.gov/
newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support -us-healthcare-system-
during-covid.
80 See Health Resources and Services Administration (HRSA), Evidence Based Telehealth Network Program ,
https://www.hrsa.gov/grants/find-funding/hrsa-21-082.
81 See, for example, U.S. Department of Veteran’s Affairs, VAMobile/COVID Coach, https://mobile.va.gov/app/covid-
coach.
82 See, for instance, T he National T elehealth Policy Resource Center, Center for Connected Health Policy, Current
State Laws and Reim bursem ent Policies, September 2020, https://www.cchpca.org/telehealth-policy/current-state-laws-
and-reimbursement -policies.
83 Ateev Mehrotra, Michael Chernew, and David Linesky, The Impact of the COVID-19 Pandemic on Outpatient Care:
Visits Return to Prepandem ic Levels, but Not for All Providers and Patients, T he Commonwealth Fund, New York,
NY, October 15, 2020, https://www.commonwealthfund.org/publications/2020/oct/impact-covid-19-pandemic-
outpatient -care-visits-return-prepandemic-levels.
84 T he National Council for Behavioral Health, Demand for Mental Health and Addiction Services Increasing as
COVID-19 Pandem ic Continues to Threaten Availability of Treatm ent Options, National Council for Behavioral Health
Member Survey Polling Presentation, Washington, DC, September 2020, https://www.thenationalcouncil.org/press-
releases/demand-for-mental-health-and-addiction-services-increasing-as-covid-19-pandemic-continues-to-threaten-
availability-of-treatment-options/.
85 Kaiser Family Foundation, Unmet Need for Counseling or T herapy Among Adults Reporting Symptoms of Anxiety
and/or Depressive Disorder During the COVID-19 Pandemic, State Health Facts, February 2021, https://www.kff.org/
other/state-indicator/unmet-need-for-counseling-or-therapy-among-adults-reporting-symptoms-of-anxiety-and-or-
depressive-disorder-during-the-covid-19-pandemic/?currentT imeframe=0&sortModel=
%7B%22colId%22:%22Location%22,%22sort %22:%22asc%22%7D.
86 Controlled Substances Act §309(e) and 21 C.F.R. §1300 et seq.
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(OUD) are typical y required to attend an initial examination in person.87 For the duration of the
public health emergency, SAMHSA and the Drug Enforcement Administration (DEA) are
al owing prescriptions for buprenorphine for OUD to a new patient via telemedicine (including
telephone) without an initial in-person examination.88 In April 2021, HHS published practice
guidelines for administering buprenorphine for OUD.89 These new guidelines exempt eligible
practitioners from certification prerequisites previously required to treat patients with
buprenorphine.90 According to HHS, this exemption addresses reported barriers to expanding
access to buprenorphine treatment.91 The exemptions in these guidelines are not subject to the
public health emergency declaration.
Typical y, most individuals receiving methadone treatment must travel to brick-and-mortar OTPs
on a daily basis to receive their dose (with some exceptions for stable and long-term patients).92
During the pandemic, SAMHSA and DEA are al owing stable patients to receive up to 28 days of
take-home medication.93 DEA is also al owing alternative methods for delivery of methadone to
patients under stay-at-home orders,94 and interstate prescribing privileges for providers.95 DEA—
the agency that provides registrations to operate OTPs—had previously published a proposed rule
al owing these facilities to operate a mobile component to administer methadone.96
Changes to Privacy Requirements
Given the large number people seeking COVID-19 treatment, testing, and vaccination,
individuals’ interactions with the health care and public health system have increased, both
virtual y and in person, during the COVID-19 pandemic. As a result, a significant amount of
clinical and related demographic and other data have been generated. A coordinated response to
the pandemic has, in many cases, relied on efforts to share health care and public health
information in new ways and more readily, and to overcome the barriers associated with doing

87 Controlled Substances Act §309(e); 21 U.S.C. §829(e).
88 Letter from T homas Prevoznik, Deputy Assistant Administrator, Diversion Control Center, to DEA Qualifying
Practitioners and DEA Qualifying Other Practitioners, DEA Registrants, March 31, 2020,
https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-
022)(DEA068)%20DEA%20SAMHSA%20buprenorphine%20telemedicine%20%20(Final)%2 0+Esign.pdf.
89 Department of Health and Human Services, “Practice Guidelines for the Administration of Buprenorphine for
T reating Opioid Use Disorder,” 86 Federal Register 22439-22440, April 28, 2021.
90 For more information, see CRS Report R45279, Buprenorphine and the Opioid Crisis: A Primer for Congress.
91 86 Federal Register 22439.
92 As outlined in 42 CFR §8.12.
93 Substance Abuse and Mental Health Services Administration, Opioid Treatment Program (OTP) Guidance,
Rockville, MD, March 16, 2020, https://www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf.
94 Letter from T homas Prevoznik, Deputy Assistant Administrator, Drug Enforcement Administration, to Registered
Narcotic T reatment Program, April 7, 2020, https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-025)(DEA078)_Off-
site_OT P_delivery_method_(Final)+_esign.pdf.
95 Letter from William McDermott, Assistant Administrator, Drug Enforcement Administration, to DEA Registrants,
March 25, 2020, https://www.deadiversion.usdoj.gov/GDP/(DEA-DC-
018)(DEA067)%20DEA%20state%20reciprocity%20(final)(Signed).pdf. DEA operates a webpage with more
information and resources related to the COVID-19 pandemic. See Drug Enforcement Administration, “ COVID-19
Informat ion Page,” https://www.deadiversion.usdoj.gov/coronavirus.html.
96 Drug Enforcement Administration, “Registration Requirements for Narcotic T reatment Programs With Mobile
Components,” 85 Federal Register 11008-11020, February 26, 2020. DEA refers to OT Ps as “narcotic treatment
programs.”
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so.97 Such efforts have resulted in certain changes to how existing privacy requirements are
enforced and highlighted other potential changes.
In response to the COVID-19 pandemic, the Office for Civil Rights (OCR) in the Department of
Health and Human Services (HHS), the agency responsible for administering and enforcing the
HIPAA rules, released numerous guidance documents and published notices of enforcement
discretion to support the sharing of health information or to clarify how such information may be
shared per the requirements of the rules. These actions are general y linked and limited to the
COVID-19 pandemic. Some of these announcements, such as those involving requirements
related to the sharing of health information in the context of telehealth, may be particularly
relevant for individuals with behavioral health conditions.
In addition, OCR publicly released a notice of proposed rulemaking on the HHS website in
December 2020 that would make numerous changes to the HIPAA Privacy Rule.98 Several of
these proposed changes—for example, modifying the standard for sharing information about
individuals experiencing health emergencies, including substance use disorder crises—could
directly affect individuals with behavioral health conditions. In addition, the Coronavirus Aid,
Relief, and Economic Security Act (CARES Act, P.L. 116-136) included a provision that
amended confidentiality requirements for sharing certain substance use disorder patient
information, requirements that are implemented by the Part 2 Rule and SAMHSA.99 The goal of
these changes was to better support care coordination and health care delivery by giving al
providers involved in a patient’s care ready access to health information in a manner similar to
the HIPAA Privacy Rule. These permanent changes are not limited to the COVID-19 pandemic;
however, broader issues with data sharing during the pandemic accelerated these changes, which
had been under debate for several years.
In general, such changes undertaken to relax or otherwise modify privacy requirements may be of
consequence to individuals with behavioral health conditions. These individuals, in particular,
may weigh the potential benefits of sharing their health data against the risks of having their
personal information shared more broadly, including their behavioral health information.
Conversely, having information more readily available in clinical care settings may provide a
specific benefit to this population, possibly supporting and resulting in better health care
outcomes, because the clinical information may be more complete and more easily integrated into
an individual’s general medical care. Having health information readily available may be
particularly important during health emergencies, for example, in cases involving opioid
overdose.
HIPAA Privacy and Security Rule
The HIPAA Privacy Rule100 governs covered entities’ (health care plans, providers, and
clearinghouses) and their business associates’ use and disclosure of protected health information
(PHI). PHI is general y defined as individual y identifiable health information, in any form or
format, including oral, paper-based, and electronic. Covered entities perform many different
functions that involve PHI, and they often need to contract with outside entities to conduct their
work. These contracted entities, or business associates, are defined as a person or organization

97 For more information, see CRS Report R46588, Tracking COVID-19: U.S. Public Health Surveillance and Data.
98 T he NPRM was published in the Federal Register on January 21, 2021. See 86 Federal Register 6446, January 21,
2021.
99 T he Part 2 Rule is codified at 42 C.F.R. Part 2, “ Confidentiality of Substance Use Disorder Patient Records.”
100 45 C.F.R. Part 164 Subpart E.
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that performs certain functions or activities on behalf of, or provides certain services to, a covered
entity that involve the use or disclosure of individual y identifiable health information.101
The use and disclosure of PHI by a business associate is general y governed by the requirements
of the HIPAA Privacy Rule, and more narrowly by specific parameters outlined in a Business
Associate Agreement (BAA) between the covered entity and the business associate. The rule’s
requirements apply only to PHI, and they do not apply to data that have been de-identified
pursuant to requirements in the rule. The rule delineates when and under what conditions covered
entities may permissibly use or disclose PHI without written authorization. Uses and disclosures
that are not expressly permitted under the rule require an individual’s prior written authorization.
Specifical y, covered entities are permitted to disclose PHI to noncovered entities for several
specific “priority purposes” that are not health care specific, without authorization from the
individual.102 These include, for example, legal y required disclosures for public health activities,
for health oversight activity, and to avert a serious threat to health or safety, among others.
In addition, the HIPAA Security Rule103 governs the security and integrity of electronic PHI
(ePHI), and the Breach Notification Rule104 requires notification to affected individuals and
covered entities, the media, and the HHS Secretary in certain cases of breaches involving
unsecured PHI.
These disclosures have taken on increased significance during the COVID-19 pandemic, because
sharing large amounts of data for public health purposes has become key to monitoring and
responding to the crisis.
As part of its response to the COVID-19 pandemic, OCR has not changed existing requirements
in the HIPAA rules, but has instead modified the enforcement of specific requirements in certain
cases. These changes wil general y remain in effect until the end of the COVID-19 public health
emergency.105 For example, OCR issued guidance in March 2020 announcing that it wil not
penalize health care providers for noncompliance when they are providing telehealth services in
good faith during the COVID-19 emergency.106 Specifical y, the notice explains that health care
providers using certain common nonpublic facing applications (e.g., Apple FaceTime or
Facebook Messenger video chat) in good faith for telehealth would not be penalized. General y,
for example, a BAA between a covered entity (health care provider) and the video
communication vendor would be required prior to providing telehealth services. Under this OCR
policy, a provider may use a video communication vendor to provide telehealth services in the
absence of a BAA, although OCR recommends that providers advise patients of the potential
privacy risks, and suggests that al available privacy and encryption modes be used when
possible.
In addition, to facilitate its response to the COVID emergency in terms of both disclosures and
the performance of certain data analytic functions, OCR published a notice of enforcement

101 45 C.F.R. §160.103.
102 See 45 C.F.R. §164.512, generally.
103 45 C.F.R. Part 164, Subpart C.
104 45 C.F.R. Part 164, Subpart D.
105 See, for example, [JD: Is something missing here?] the notice of enforcement discretion allowing business
associates to share PHI for public health purposes, noting that the changes will “ remain in effect until the Secretary of
HHS declares that the public health emergency no longer exists, or upon the expiration date of the declared public
health emergency (as determined by 42 U.S.C. 247d), whichever occurs first .” 85 Federal Register 19392, April 7,
2020.
106 85 Federal Register 22024, April 21, 2020.
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discretion al owing business associates to share PHI for public health purposes in a manner that
might not be expressly permitted by their BAA.107 Due to the requirements relating to the BAA in
the Privacy Rule, certain entities serving as business associates were delayed or unable to respond
to requests for certain public health data. This enforcement discretion aims to address that issue
and to facilitate rapid public health monitoring during the pandemic. The scope of this policy is
limited only to certain specified Privacy Rule provisions, and it does not extend to requirements
under the Security or Breach Notification Rules.
In December 2020, OCR issued a public Notice of Proposed Rulemaking (NPRM) proposing
several modifications to the HIPAA Privacy Rule to broadly facilitate care coordination and to
reduce the burden of compliance on providers.108 Several of these proposed changes, which had
been under discussion since publication of a December 2018 Request for Information (RFI)
soliciting comments on possible changes to the rule,109 may be of special relevance to individuals
with behavioral health conditions. Specifical y, the proposed rule proposes modifying the
language regarding the al owance for lawful disclosure when there is a “serious or imminent
threat” to health or safety.110 This disclosure, which may be made by a covered entity to a
noncovered entity without individual authorization, is significant because the information, once
held by a noncovered entity, is no longer subject to the Privacy Rule’s requirements. The NPRM
proposes to change this disclosure language from “serious or imminent threat to the health or
safety” to “serious and reasonably foreseeable” harm. This change is meant to provide a less strict
standard for disclosure, one that does not require a provider to determine if a threat is
“imminent,” but rather only foreseeable. If finalized, this change may result in more disclosures
of potential y sensitive information.
Many providers may be unaware that the Privacy Rule al ows them to share PHI in certain cases
when an individual is incapacitated. Providers may be unfamiliar with the rule’s specific
requirements in these cases, or may be bound by potential y more stringent state laws or
professional ethics. Currently, providers may share PHI with family and friends involved in an
individual’s care if the individual is unable to agree or object to the disclosure, based on the
providers’ professional judgment.111 The December 2020 NPRM proposes to substitute the
current phrase “exercise of professional judgement” with “good faith belief” in an effort to
expand “the ability of covered entities to disclose PHI to family members and other caregivers
when they believe it is in the best interests of the individual … without the covered entity having
undue fear of violating HIPAA.”112 This change aims to help individuals experiencing a health
crisis related to substance use disorder or serious mental il ness, among others, by making it
easier for family and friends to care for them, especial y if they are incapacitated.
Together, these actions and proposed changes general y support expanding the timely sharing of
information, in certain cases without explicit authorization. In certain cases, these changes may
benefit patients (e.g., sharing information when an individual is incapacitated). In other cases,
these changes may benefit the broader public (e.g., disclosures related to monitoring the
pandemic or averting a serious threat to health or safety). However, these benefits are being

107 85 Federal Register 19392, April 7, 2020.
108 T he NPRM was published in the Federal Register in January 2021. See 86 Federal Register 6446, January 21,
2021. Comments are due by May 6, 2021.
109 83 Federal Register 64302, December 14, 2018.
110 45 C.F.R. §164.512(j).
111 45 C.F.R. §164.510(b).
112 Office for Civil Rights, “ Office for Civil Rights (OCR) Proposes Modifications to the HIPAA Privacy Rule to
Empower Individuals, Improve Coordinated Care, and Reduce Regulatory Burdens FACT SHEET ,” December 10,
2020, https://www.hhs.gov/sites/default/files/hipaa-nprm-factsheet.pdf.
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weighed against privacy concerns and the potential risk of sharing sensitive information too
broadly, with individuals unable to specifical y control what information is being shared and with
whom. Although the issue of privacy is being debated both at the state and federal levels, it is
unclear whether these temporary changes wil be made permanent or finalized through
rulemaking in the future.
CARES Act: Harmonizing the Part 2 Rule with the HIPAA Privacy Rule
Beyond the context of the COVID-19 pandemic, the CARES Act made changes, not limited to
the emergency period, to requirements governing confidentiality of substance use disorder
records. Promulgated in the “Part 2” Rule, these requirements apply to individual y identifiable
patient information received or acquired by federal y assisted substance use disorder programs.113
The Part 2 Rule is general y considered to be one of the strictest privacy law s in effect, due in
large part to the stigma associated with seeking treatment for substance use disorders.
The CARES Act al ows covered information to be shared in a manner more aligned with HIPAA
Privacy Rule requirements regarding treatment, payment, or health care operations information
shared between and among covered entities without authorization. Although an initial consent
wil be required for such sharing of records to occur, once that consent is given, the records may
be disclosed for PHI as they are under the Privacy Rule for the purposes of treatment, payment,
and health care operations. The specifics of the consent requirement were not addressed by the
CARES Act and could be included in promulgating regulations.
The changes made by the CARES Act seek to balance improved care coordination for individuals
with substance use disorders with the heightened privacy interest around sensitive information,
reflecting that the delivery of health care has changed significantly since the substance use
disorder confidentiality requirements became law. Although the CARES Act requires the
Secretary to revise Part 2 or other regulations as necessary with respect to uses and disclosures of
covered records one year after enactment (i.e., March 27, 2021), HHS has not yet promulgated
these regulations. SAMHSA recently noted that it expects to publish these regulations later in
2021, in conjunction with OCR. In the interim, the current Part 2 regulations wil remain in
effect.114
Changes to Mental Health Parity
Mental health parity refers to the requirement that health insurance issuers provide equivalent
terms for the coverage of mental health services as provided for medical and surgical services.115
Mental health services include counseling, psychotherapy, and substance use treatment, among
others. Federal parity law does not require private health insurance, Medicaid, or CHIP to offer
mental health benefits (although other areas of federal law mandate such benefits in some cases).
Rather, when both mental health benefits and medical/surgical benefits are offered, federal parity

113 PHSA §543 “Confidentiality of Records”; 42 U.S.C. § 290dd–2. T he Part 2 Rule is codified at 42 C.F.R. Part 2,
“Confidentiality of Substance Use Disorder Patient Records.”
114 SAMHSA, “ Statement on 42 CFR Part 2 Amendments Process,” April 9, 2021, https://www.samhsa.gov/newsroom/
statements/2021/42-cfr-part-2-amendments-process.
115 Federal parity law is explicitly directed at private health insurance. T he law is applied to Medicaid and the
Children’s Health Insurance Program through the statute governing private health insurance.
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law general y prohibits the insurer from imposing more restrictive limits—including quantitative
and nonquantitative treatment limitations—on the mental health benefits.116
A provision in the Consolidated Appropriations Act, 2021 (P.L. 116-260), attempts to strengthen
federal oversight of insurers’ compliance with mental health parity laws and regulations by
requiring group health plans and health insurance issuers to perform and document comparative
analyses of nonquantitative treatment limitations for mental health and substance use disorder
benefits and medical and surgical benefits. 117 The provision requires HHS and the Department of
Labor to request and review at least 20 comparative analyses from group health plans and health
insurance issuers that may involve a violation or a complaint regarding noncompliance with
mental health parity requirements. The information in the comparative analyses is to be used to
determine compliance, as wel as develop guidance to help group health plans and health
insurance issuers comply with mental health parity requirements.
Changes to Behavioral Health Funding
The COVID-19 pandemic has limited in-person health service visits and caused economic
hardships, resulting in behavioral health clinic closures and other reductions to treatment service
capacity.118 In response to this decreasing capacity, Congress sought to address the high demand
for mental health and substance use disorder treatment services through emergency financial
support for behavioral health activities provided in three of the supplemental COVID-19 funding
laws.
The CARES Act appropriated $425 mil ion to SAMHSA to support behavioral health services
during the pandemic. This amount included $250 mil ion for the Certified Community Behavioral
Health Clinic (CCBHC) Expansion grant program and $50 mil ion for suicide prevention. Of the
remaining total, $110 mil ion went to states in the form of emergency grants to provide crisis
intervention services, mental and substance use disorder treatment, and other related recovery
supports for children and adults affected by the COVID-19 pandemic.119 SAMHSA gave states
significant flexibility in how to use these funds to support behavioral health-related activities.120
In addition, Congress established the Provider Relief Fund (PRF) in the CARES Act. The
measure appropriated $100 bil ion “to reimburse, through grants or other mechanisms, eligible
health care providers for health care related expenses or lost revenues that are attributable to

116 Quantitative treatment limitations include, but are not limited to, annual, episode, and lifetime day and visit limits.
Nonquantitative treatment limitations include medical management standards limiting benefits based o n medical
necessity, prior authorization requirements, and treatment exclusions for certain conditions, among others. For the
definition of “treatment limitations,” see 45 C.F.R. §146.136. For a list of quantitative and nonquantitative treatment
limitations, see https://www.dol.gov/sites/dolgov/files/EBSA/la ws-and-regulations/laws/mental-health-parity/self-
compliance-tool.pdf.
117 Division BB, T itle II, §203 of P.L. 116-260, Consolidated Appropriations Act, 2021 (42 U.S.C. 300gg-26(a)).
118 T he National Council for Behavioral Health, Demand for Mental Health and Addiction Services Increasing as
COVID-19 Pandem ic Continues to Threaten Availability of Treatm ent Options, National Council for Behavioral
Health Mem ber Survey Polling Presentation, Washington, DC, September 2020, https://www.thenationalcouncil.org/
press-releases/demand-for-mental-health-and-addiction-services-increasing-as-covid-19-pandemic-continues-to-
threaten-availability-of-treatment-options/.
119 Eligibility included territories and tribes/tribal organizations. See Substance Abuse and Mental Health Services
Administration, Em ergency Grants to Address Mental Health and Substance Use Disorders during COVID -19,
Funding Opportunity Announcement FG-20-006, April 1, 2020, https://www.samhsa.gov/grants/grant -announcements/
fg-20-006.
120 SAMHSA operates a webpage dedicated to other initiatives and information related to the novel coronavirus
pandemic, including a webpage specific to MAT . T he webpage can be found at https://www.samhsa.gov/coronavirus.
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coronavirus.” The PRF provides grants to eligible health care providers. Funds do not have to be
repaid as long as the provider meets the PRF’s terms and conditions.121 The Paycheck Protection
Program and Health Care Enhancement Act (PPPHCEA, P.L. 116-139)—the fourth COVID-19
supplemental measure—added an additional $75 bil ion to the PRF.
Certified Community Behavioral Health Clinics
The Protecting Access to Medicare Act of 2014 (P.L. 113-193) created a program to improve community-based
behavioral health services through a demonstration program. Certified community behavioral health clinics
(CCBHCs) are facilities operated by nonprofit organizations and governmental or tribal entities that offer a
comprehensive range of services, including risk assessment, outpatient mental health and substance use treatment,
case management, psychiatric rehabilitation services, peer and family supports, 24 -hour crisis management, and
primary care medical services, among others.122 Federal funding provided through the CCBHC program helps
community behavioral health clinics provide the services required for certification. To be certified, CCBHCs are
required to maintain partnerships with other health and social service providers.
In 2015, 24 states received planning grants, and in 2016, 8 states were selected to participate in the initial
demonstration program. These states receive an enhanced Medicaid federal medical assistance percentage (FMAP;
i.e., federal matching) rate for CCBHC services, and the CCBHCs in these states received an enhanced payment
rate through a prospective payment system methodology.123 Two additional states were added to the
demonstration program in 2020.124
In 2019, the Further Consolidated Appropriations Act, 2020 (P.L. 116-94), authorized a CCBHC Expansion grant
program. CCBHC Expansion Grants provided up to $2 mil ion to facilities that met the certification criteria to
increase access and improve the quality of their behavioral health services. (Only CCBHCs in the Demonstration
program receive the enhanced Medicaid rate.) In 2020, 33 states were participating in the CCBHC Demonstration
and Expansion grant programs.125
The fifth COVID-19 supplemental funding measure (P.L. 116-260) appropriated $4.25 bil ion to
SAMHSA in supplemental COVID-related funding.126 Of this amount, $1.65 bil ion was
designated for each of SAMHSA’s two main block grants: the Substance Abuse Prevention and
Treatment Block Grant (SABG) and the Community Mental Health Services Block Grant
(MHBG). The SABG and MHBG are SAMHSA’s two largest grant programs.127 Both block
grant programs distribute funds to states (including the District of Columbia and territories)
according to a formula specified in statute.128 The states, in turn, may distribute funds to local
government entities and nonprofit organizations for behavioral health-related treatment and
prevention activities in accordance with a plan the state submits to SAMHSA. The provision in
P.L. 116-260 maintained a 20% set-aside for prevention-related activities.

121 For more information, see CRS Insight IN11438, The COVID-19 Health Care Provider Relief Fund.
122 §223 of P.L. 113-93, Protecting Access to Medicare Act of 2014.
123 SAMHSA, Section 223 Demonstration Program for Certified Community Behavioral Health Clinics, last updated
October 11, 2018, https://www.samhsa.gov/section-223.
124 §3814 of P.L. 116-136, the Coronavirus Aid, Relief, and Economic Security Act .
125 T he National Council for Behavioral Health, CCBHCs: A New Model for Behavioral Health Gaining Momentum in
States, Events, Washington, DC, January 29, 2021, https://www.thenationalcouncil.org/?api&do=attachment&name=
ccbhcs-a-new-model-for-behavioral-health-gaining-momentum-in-states.
126 T his amount was in addition to SAMHSA’s annual FY2021 appropriations, which were also included in the law.
127 For more information, see CRS Report R46426, Substance Abuse and Mental Health Services Administration
(SAMHSA): Overview of the Agency and Major Program s.
128 PHSA T itle XIX. For more information, see CRS Report R46426, Substance Abuse and Mental Health Services
Adm inistration (SAMHSA): Overview of the Agency and Major Program s.
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Of the total appropriated to SAMHSA in P.L. 116-260, not less than $240 mil ion was reserved
for emergency response activities.129 The law designated $600 mil ion to the CCBHC Expansion
grant program and $50 mil ion for suicide prevention. The law also designated $50 mil ion to
SAMHSA’s Project AWARE program, which supports school-based mental health training and
referral services in elementary and secondary education. Another $10 mil ion was designated for
the National Child Traumatic Stress Initiative (NCTSI).130
In March 2021, a budget reconciliation measure developed in response to the pandemic —the
American Rescue Plan Act (ARPA; P.L. 117-2)—provided another $1.5 bil ion to each of
SAMHSA’s main block grant programs: the MHBG and SABG.131 The measure provided $50
mil ion to “address increased community behavioral health needs worsened by the COVID-19
public health emergency”132 and another $30 mil ion to support “community-based overdose
prevention programs, syringe services programs, and other harm reduction services.”133 The
CCBHC Expansion grant program received $420 mil ion, Project AWARE received $30 mil ion,
NCTSI received $10 mil ion, and $20 mil ion was provided for youth suicide prevention
activities.
In addition to SAMHSA appropriations, ARPA provided $80 mil ion to HRSA for pediatric
mental health care, which includes expansion of telehealth services. HRSA received $120 mil ion
to promote mental health among health professionals and to reduce suicide, burnout, and mental
health conditions among the health care workforce. CDC received $20 mil ion for a behavioral
health education and awareness campaign directed at health care professionals and first
responders.134
Other Federal Efforts
During the COVID-19 pandemic, Congress has periodical y requested that the Comptroller
General of the Government Accountability Office (GAO) monitor and report on federal efforts
related to the pandemic.135 In November 2020, GAO published a report summarizing federal
efforts during the pandemic and provided recommendations for federal action.136 GAO reported
the following behavioral health-related federal activities during the COVID-19 pandemic:
 CDC, in addition collecting data, has operated websites promoting strategies for
good mental wel -being during the COVID-19 pandemic.

129 As authorized in PHSA §501(o).
130 T he National Child T raumatic Stress Initiative aims to improve behavioral health services for children exposed to
traumatic events. Grant funding supports development and promotion of effective community practices, mostly through
information and trainings by a network of centers known as the National Child T raumatic Stress Network.
131 See the House Budget Committee report (H.Rept. 117-7) for a discussion of the context surrounding the American
Rescue Plan Act of 2021 (ARPA; P.L. 117-2).
132 ARPA §2707.
133 ARPA §2706.
134 Some studies have shown increased anxiety, depression, sleep problems, and distress among health care workers
during the COVID-19 pandemic. See, for example, Ashley E. Muller, Elisabet V. Hafstad, Jan P. W. Himmels, et al.,
“T he Mental Health Impact of the COVID-19 Pandemic on Healthcare Workers, and Interventions to Help T hem: A
Rapid Systematic Review,” Psychiatry Research, vol. 293 (November 2020).
135 See, for instance, several provisions in P.L. 116-136, the CARES Act.
136 U.S. Government Accountability Office, COVID-19 Urgent Actions Needed to Better Ensure an Effective Federal
Response, 21-191, November 2020, https://www.gao.gov/assets/gao-21-191.pdf.
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 HRSA has supported grantees in their efforts to provide or expand access to
behavioral health services. The agency has also focused on increasing access to
telebehavioral health services and supported providers through its administration
of the Provider Relief Fund.
 NIH has granted COVID-19 specific research awards for behavioral health
research and internal y conducted research related to the behavioral health
impacts of the COVID-19 pandemic.
 The HHS Office of the Assistant Secretary for Preparedness and Response
(ASPR) deployed 20 National Disaster Medical System mental health specialists,
both in-person and virtual y, to help address behavioral health needs related to
the COVID-19 pandemic.
 The Commissioned Corps deployed behavioral health officers in support of the
COVID-19 pandemic response.
 The Federal Emergency Management Agency (FEMA) and SAMHSA awarded
grants to 48 states through its Crisis Counseling Assistance and Training Program
(CCP).137
On October 3, 2020, President Trump signed an executive order creating a Coronavirus Mental
Health Working Group to outline a plan for improving the federal mental health response.138
Issues for Congress
Congress and the executive branch of the federal government—in addition to state and local
governments—continue to face decisions related to the COVID-19 pandemic, including those
affecting behavioral health treatment and prevention. Below are select behavioral health-related
issues Congress may consider during the pandemic and beyond.
Extending Changes to Mental Health and Substance Use
Disorder Treatment
One issue for Congress and the executive branch is how long to maintain changes to substance
use disorder (SUD) service delivery after the pandemic. For the most part, the federal government
defers to states and lets them regulate the practice of medicine. One exception pertains to using
the controlled substances methadone and buprenorphine in medication-assisted treatment (MAT)
for opioid use disorder. Regulations on methadone and buprenorphine—such the use of telehealth
in MAT—are rooted in concerns about diversion of these substances.139 Some public health
experts and policymakers have advocated for permanently al owing the telehealth and substance
use disorder treatment exceptions instituted during the pandemic.140 Some have argued that the

137 Ibid., pp. 151-164.
138 Executive Order 13954, “Saving Lives T hrough Increased Support for Mental- and Behavioral-Health Needs,” 85
Federal Register 63977-63979, October 3, 2020. For more information, see https://www.samhsa.gov/sites/default/files/
saving-lives-mental-behavioral-health-needs.pdf.
139 For more information, see CRS Report R45279, Buprenorphine and the Opioid Crisis: A Primer for Congress.
140 Bridget C.E. Dooling and Laura Stanley, Extending Pandemic Flexibilities for Opioid Use Disorder Treatment:
Telem edicine & Initiating Buprenorphine Treatm ent, T he George Washington University Regulatory Studies Center,
Report I of the Extending Pandemic Flexibilities for Opioid Use Disorder T reatment Project, Washington, DC,
February 23, 2021, https://regulatorystudies.columbian.gwu.edu/telemedicine-initiating-buprenorphine-treatment.
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pre-pandemic regulations are overly restrictive and inhibit access to SUD treatment such as
MAT.141 Others have claimed that making medications such as buprenorphine and methadone
more accessible wil increase the diversion of these substances and lead to adverse
consequences.142 DEA has stated that without congressional action, the exceptions that DEA has
issued during the pandemic related to telemedicine and substance use disorder treatment though
MAT wil expire at the end of the public health emergency declarations.143
In May 2020, a group of Members of the House of Representatives encouraged greater data
collection to inform decisions regarding which, if any, of the pandemic flexibilities should be
made permanent.144 Exceptions to SUD treatment provision during the pandemic could create a
naturalistic experiment on the effects of these temporary policies. Research could provide insights
on possible consequences to providing greater flexibilities, such as increased accessibility to
MAT, increased diversion, or both. In April 2021, the Office of National Drug Control Policy
(ONDCP) released its annual drug policy priorities, stating it would “evaluate and explore
making permanent the emergency provisions” implemented during the pandemic.145 Executive
agencies may have the authority to make certain changes permanent, while others would require
statutory changes made by Congress.146
In its brief report on behavioral health services during the pandemic, GAO noted that most of the
stakeholder groups it interviewed (composed mostly of hospital system associations) reported
positive effects of the increased use of and payment for telehealth.147 The stakeholders believed
that these changes improved access to behavioral health services for many patients not requiring

141 Ibid., and Corey S. Davis and Elizabeth A. Samuels, “Continuing Increased Access to Buprenorphine in the United
States via T elemedicine after COVID-19,” The International Journal on Drug Policy, August 15, 2020.
142 For more information, see CRS Report R45279, Buprenorphine and the Opioid Crisis: A Primer for Congress.
Some studies have suggested that buprenorphine diversion in the United States stems from difficulties in accessing the
medication legally, and that removing some of the regulations to increase access may actually reduce diversion. See,
for example, Howard D. Chilcoat, Halle R. Amick, Molly R. Sherwood, et al., “Buprenorphine in the United States:
Motives for Abuse, Misuse, and Diversion,” Journal of Substance Abuse Treatment, vol. 104 (September 2019), pp.
148-157; Michelle R. Lofwall and Sharon Walsh, “ A Review of Buprenorphine Diversion and Misuse: T he Current
Evidence Base and Experiences from Around the World,” Journal of Addiction Medicine, vol. 8, no. 5 (Sept.-Oct.
2014); and T heodore J. Cicero, Matthew S. Ellis, Howard D. Chilcoat, et al., “ Understanding the Use of Diverted
Buprenorphine,” Drug and Alcohol Dependence, vol. 193 (December 2018), pp. 117-123.
143 Scott Brink, Section Chief, Drug Enforcement Administration, remarks at the American College of Medical
T oxicology, Mitigating the Intersection of COVID-19 and Opioid Use Disorder, COVID-19 webinar, May 21, 2020,
43:06, https://www.youtube.com/watch?v=t_Iu9t -AJug. Section Chief Brink stated, “ Once the declared public health
emergency expires all these exceptions to regulations and guidance documents that DEA issued, they will expire when
the public health emergency expires. T elemedicine will also return to how it was before the COVI D-19 public health
emergency. T elemedicine or the Ryan Haight Act are law. T hey are in statute and they can only be changed by
Congress. DEA does not have the ability to change those.”
144 Letter from T om Emmer, Member of Congress, Paul T onko, Member of Congress, and T ony Cardenas, Member of
Congress, et al. to Nancy Pelosi, Speaker of the House, and Mitch McConnell, Senate Majority Leader, May 21, 2020,
https://emmer.house.gov/_cache/files/e/7/e71a1dae-7716-4a4f-ac7a-ab339fc71f8e/
CC1592FCF331D833D6EA42B18EEBBA68.telehealth -letter.pdf.
145 Executive Office of the President Office of National Drug Control Policy, “The Biden -Harris Administration’s
Statement of Drug Policy Priorities for Year One,” press release, April 1, 2021.
146 See, for example, Bridget C.E. Dooling and Laura Stanley, Extending Pandemic Flexibilities for Opioid Use
Disorder Treatm ent: Telem edicine & Initiating Buprenorphine Treatm ent, T he George Washington University
Regulatory Studies Center, Report I of the Extending Pandemic Flexibilities for Opioid Use Disorder T reatment
Project, Washington, DC, February 23, 2021, https://regulatorystudies.columbian.gwu.edu/telemedicine-initiating-
buprenorphine-treatment.
147 U.S. Government Accountability Office, Behavioral Health: Patient Access, Provider Claims Payment, and the
Effects of the COVID-19 Pandem ic, GAO-21-437R, April 30, 2021, https://www.gao.gov/products/gao-21-437r.
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in-person services and resulted in fewer missed appointments. In addition, some experts have
lauded efforts to expand telehealth capacity, but warned that without proactive measures,
expanding telehealth could increase disparities in health care access for vulnerable populations
with limited digital literacy or access, such as rural residents, racial/ethnic minorities, older
adults, and those with low income.148
Mental Health Effects of Stay-at-Home Orders
Congress may play a role in influencing the timeline for reopening certain parts of the country
and the mental health consequences of the COVID-19 pandemic. Although stay-at-home orders
and other pandemic-related mitigation policies are determined at the state level, Congress could
provide encouragement or incentives for maintaining or removing those policies. Decisions about
maintaining or relaxing mitigation strategies could have implications for mental health and
substance use. Determining the extent to which increased mental health symptoms have been
caused by isolation related social distancing and stay-at-home orders rather than by anxieties
about the coronavirus, economic consequences of the pandemic, or other reasons is difficult. As
mentioned above, the data suggest that pandemic-related mitigation strategies have influenced
mental distress and loneliness.149 If stay-at-home orders are related to increased social isolation,
anxiety, or depression, policymakers may take that correlation—and the tradeoffs it presents—
into consideration when determining timelines for reopening. For example, the mental wel -being
of children and adolescents (and their parents) could be factored into decisions about returning to
synchronous learning in schools.150 On one hand, asynchronous learning at home may have
increased stress for some students and parents.151 On the other hand, returning to in-classroom
learning in schools could slow moderation of the pandemic, further exacerbating stress for many
individuals.152
Some mental health issues may have been caused by the COVID-19 pandemic itself, in which
case, the mental distress it caused may dissipate for many individuals as the pandemic subsides.
Given that concerns about the pandemic or fears of the virus have driven mental health issues
during the pandemic, strategies to temper the pandemic as soon as possible—such as stay-at-
home orders or vaccine distribution—may be prioritized. For individuals with mental health

148 Sarah Nouri, Elaine C. Khoong, Courtney R. Lyles, et al., “Addressing Equity in T elemedicine for Chronic Disease
Management During the COVID-19 Pandemic,” NEJM Catalyst, May 4, 2020, https://catalyst.nejm.org/doi/pdf/
10.1056/CAT .20.0123.
149 Emma McGinty, Rachel Presskreischer, Hahrie Han, et al., “Psychological Distress and Loneliness Reported by US
Adults in 2018 and April 2020,” JAMA, vol. 324, no. 1 (June 3, 2020). See also N. Leigh-Hunt, D. Bagguley, K. Bash,
et al., “An Overview of Systematic Reviews on the Public Health Consequences of Social Isolation and Loneliness,”
Public Health, vol. 152 (November 2017), pp. 157 -171.
150 Little research exists on the mental health effects of the pandemic on children. Some data suggest that mental health
issues have increased in this population, as illustrated by higher mental health -related emergency department visits
throughout 2020. See Rebecca Leeb, Rebecca Bitsko, and Lakshmi Radhakrishnan, Mental Health-Related Em ergency
Departm ent Visits Am ong Children Aged <18 Years During the COVID-19 Pandem ic - United States January 1-
October 17, 2020, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), vol.
69, no. 45, November 13, 2020, https://www.cdc.gov/mmwr/volumes/69/wr/mm6945a3.htm.
151 See, for instance, Stephen W. Patrick, Laura E. Henkhaus, Joseph S. Zickafoose, et al., “Well-Being of Parents and
Children During the COVID-19 Pandemic: A National Survey,” Pediatrics, vol. 146, no. 4 (October 2020); and
Panchal et al., The Im plications of COVID-19 for Mental Health and Substance Use, 2021.
152 T he Biden Administration—through executive orders and other efforts—has indicated that it intends to support
efforts to create the conditions necessary for safe, in-person learning as quickly as possible. See Executive Order
14000, “Supporting the Reopening and Continuing Operation of Schools and Early Childhood Education Providers,”
86 Federal Register 7215-7218, January 26, 2021.
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issues that continue beyond the pandemic (or if the pandemic itself continues long-term), direct
interventions may be necessary. Some public health experts have suggested that addressing the
mental health impact of the pandemic on individuals and the general population wil require, in
particular, greater surveil ance of problems, a more robust treatment delivery system, and
strategies to combat loneliness.153
Oversight of Funding and Federally Supported Activities
The COVID supplemental appropriations acts and ARPA together provided SAMHSA and other
HHS agencies over $8 bil ion to address behavioral health-related needs. Much of this funding
was to be provided in the form of emergency grants or block grants to states, with substantial
flexibility regarding the use of funds. Congress, in its oversight capacities, may choose to monitor
how the funds are spent and which activities they support—a process that could occur over
several years. (In some cases, the grant funding is available until expended. In other cases, the
behavioral health funding is to be expended in FY2021.) Given the current behavioral health
infrastructure, states may face chal enges expending such a large influx of funding in a short
amount of time. Such a funding influx may help states address the immediate behavioral health
needs during the pandemic, but not the potential long-term behavioral health consequences
associated with it.
In addition, without more sustainable supports, an infusion of funding in a single fiscal year could
create a funding cliff for behavioral health activities initiated during the pandemic. Congress may
consider providing more sustainable financial support for behavioral health-related activities
instituted or expanded during the pandemic but needed beyond FY2021. Depending on the extent
to which such funding is provided during the annual appropriations process, this financial support
might require a more substantial funding al ocation for the annual appropriations bil that funds
SAMHSA, or real ocating funding for other purposes within that bil . The behavioral health
funding that is available until expended may mitigate the threat of a fiscal cliff, as states and
grantees can plan for expenditures beyond FY2021.
Congress, in its oversight capacity, may play an important role in monitoring how pandemic-
related behavioral health funding is used. Much of the statutory language authorizing and
appropriating funding for behavioral health-related activities al owed agencies and grantees to
determine how the funds are spent. In addition, much of the funding is to be provided to states via
block grants, which gives states significant flexibility regarding the use of funds. Congress may
decide to monitor such spending to ensure that federal funds are supporting intended activities,
such as evidence-based prevention and treatment interventions, for example. In addition,
Congress may consider encouraging data collection on populations served and outcomes of
federal y supported mental health and substance use activities.
Behavioral Health Disparities
The consequences of the COVID-19 pandemic—including the behavioral health effects—have
not been equal y distributed among demographic groups. For example, CDC data show that
mental distress and substance use have disproportional y affected younger individuals,
individuals with lower educational attainment and income, essential workers and unemployed

153 Sandro Galea, Raina M. Merchant, and Nicole Lurie, “T he Mental Health Consequences of COVID -19 and Physical
Distancing: T he Need for Prevention and Early Intervention,” JAMA Internal Medicine, vol. 180, no. 6 (June 2020), pp.
817-818.
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individuals, and communities of color, among others. One analysis suggested that “the emotional
costs of the pandemic are much higher for the poor and vulnerable than they are for the rich,
heightening deep pre-existing inequities in wel -being in the U.S and many other countries.”154
Congress could consider the disproportionate impact of the pandemic on certain groups when
directing behavioral health-related efforts during the pandemic. Reaching these groups may
involve special consideration regarding availability of services, access to behavioral health
resources, requirements for cultural competencies, and sustainability of benefits. As Congress
conducts oversight on federal efforts to address mental health and substance use, it may consider
the extent to which these endeavors reach the populations most in need.

154 Carol Graham, The Human Costs of the Pandemic: Is It Time to Prioritize Well-Being?, Brookings Institution,
Reimagining the Global Economy: Building Back Better in a Post -Covid-19 World, Washington, DC, November 17,
2020, https://www.brookings.edu/research/the-human-costs-of-the-pandemic-is-it-time-to-prioritize-well-being/.
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Appendix. Mental Health Symptomology in the
United States
Figure A-1. Mental Health Symptomology in the United States, by Income
Symptoms of Anxiety and Depression, April 2020 – June 2020

Source: CRS analysis of U.S. Census Bureau, Measuring Household Experiences during the Coronavirus Pandemic,
Household Pulse Survey, https://www.census.gov/data/experimental-data-products/household-pulse-survey.html.
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Notes: Estimates show the percentage of adults who report symptoms of anxiety or depression that have been
shown to be associated with diagnoses of generalized anxiety disorder or major depressive disorder. These
symptoms general y occur more than half the days or nearly every day. Percentages may not add to totals due to
rounding.
Figure A-2. Mental Health Symptomology in the United States over Time
Symptoms of Anxiety and Depression, September 2020 – May 2021

Source: CRS analysis of U.S. Census Bureau, Measuring Household Experiences during the Coronavirus Pandemic,
Household Pulse Survey, https://www.census.gov/data/experimental-data-products/household-pulse-survey.html.
Notes: Estimates show the percentage of adults who report symptoms of anxiety or depression that have been
shown to be associated with diagnoses of generalized anxiety disorder or major depressive disorder. These
symptoms general y occur more than half the days or nearly every day. Percentages may not add to totals due to
rounding.

Author Information

Johnathan H. Duff
Paul D. Romero
Analyst in Health Policy
Research Assistant

Amanda K. Sarata

Specialist in Health Policy

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Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should n ot be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
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