Behavioral Health and COVID-19: Higher-Risk Populations and Related Federal Relief Funding
Summary
GAO report GAO-22-104437 to congressional committees, Behavioral Health and COVID-19: Higher-Risk Populations and Related Federal Relief Funding, dated December 2021. Based on 32 interviews and a review of selected research, GAO found that certain populations may be at higher risk of behavioral health effects related to the pandemic, with six populations cited by the most stakeholders, including children and adolescents. The report states that, as of November 2021, the federal government had awarded over $8 billion in COVID-19 relief funding for behavioral health, over 97 percent of it through one Federal Emergency Management Agency program and five SAMHSA programs. SAMHSA awarded about $5.3 billion through block grant supplements, and FEMA about $467 million through the Crisis Counseling Assistance and Training Program.
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United States Government Accountability Office
Report to Congressional Committees
BEHAVIORAL HEALTH
December 2021
AND COVID-19
Higher-Risk
Populations and
Related Federal Relief
Funding
GAO-22-104437
December 2021
BEHAVIORAL HEALTH AND COVID-19
Higher-Risk Populations and Related Federal Relief
Funding
Highlights of GAO-22-104437, a report to
congressional committees
Why GAO Did This Study What GAO Found
The COVID-19 pandemic has had The effects of the COVID-19 pandemic and related economic crisis—such as
repercussions for the behavioral health increased social isolation, stress, and unemployment—have intensified concerns
of the nation. During the pandemic, about the number of people in the U.S. affected by behavioral health conditions:
U.S. adults have reported higher rates mental health and substance use disorders. Based on 32 interviews with federal,
of anxiety and depression symptoms state, and other stakeholders, and a review of selected research, GAO found that
and substance use. To address related certain populations may be at higher risk of new or exacerbated behavioral
concerns, the CARES Act; the health symptoms or conditions related to the pandemic. Six populations were
Consolidated Appropriations Act, 2021; cited by the most stakeholders as being at higher risk of such behavioral health
and the American Rescue Plan Act of
effects for a range of reasons. Children and adolescents, for example, had rising
2021 appropriated relief funds
rates of behavioral health conditions before the pandemic and then faced
specifically for behavioral health.
disruptions to school-based behavioral health services, stakeholders said. They
The CARES Act includes a provision also said that people may be part of multiple higher-risk populations, though not
for GAO to report on its ongoing everyone at risk will develop symptoms or conditions. Stakeholders cautioned
monitoring and oversight efforts related that with the COVID-19 pandemic ongoing, it will take time to determine how
to the COVID-19 pandemic. This report different populations may be affected in the long term.
describes (1) populations that may be
at higher risk of behavioral health Populations Cited by the Most Stakeholders as Being at Higher Risk of Behavioral Health
effects; (2) the amount and type of Effects
funding the federal government
provided in COVID-19 relief to address
behavioral health needs; and (3)
whether COVID-19 relief funds for
behavioral health could serve higher-
risk populations, and how selected
funding recipients plan to use these
funds. GAO will continue to monitor
behavioral health issues as part of As of November 2021, the federal government awarded over $8 billion in COVID-
ongoing COVID-19 related oversight. 19 relief funding for behavioral health. Over 97 percent of this funding was
To conduct this work, GAO reviewed provided to states and other recipients through six programs: one Federal
selected research on COVID-19 and Emergency Management Agency program, and five Substance Abuse and
behavioral health, and relevant federal Mental Health Services Administration (SAMHSA) programs. For example,
funding opportunity and awards SAMHSA awarded about $5.3 billion to 50 states, Washington, D.C., eight U.S.
documents. GAO also interviewed territories and other jurisdictions, and one tribe through supplements to existing
stakeholders, such as federal officials, substance abuse and mental health block grants using standard statutory
researchers, and grantees. Grantees formulas. The Federal Emergency Management Agency also awarded about
included state officials and providers in $467 million to 46 states, Washington, D.C., and four U.S. territories via the
four states and Washington, D.C., Crisis Counseling Assistance and Training Program.
selected based on state behavioral
health metrics and CARES Act-funded GAO’s review of program documentation shows that the COVID-19 relief funds
grants received, among other factors. for behavioral health, as awarded through the six programs, could generally
serve the six higher-risk populations identified by stakeholders. Selected funding
GAO incorporated technical comments recipients in four states and Washington, D.C., reported varying ways they were
from the departments of Health and using, or planned to use, relief funds to reach higher-risk populations. For
Human Services and Homeland example, officials in one state said they planned to use some mental health block
Security, as appropriate.
grant funds to assist children and adolescents in the child protective services
View GAO-22-104437. For more information, system. SAMHSA officials said that it would take time to determine who was
contact Alyssa M. Hundrup at (202) 512-7114 actually served by COVID-19 relief funded programs, but said that it was
or hundrupa@gao.gov. important to examine grantee data to determine whether target populations were
reached and identify any gaps, and the agency planned to do so.
United States Government Accountability Office
Contents
Letter 1
Background 5
Certain Populations, Such As People from Certain Racial and
Ethnic Groups, May Be at Higher Risk of Behavioral Health
Effects; Pandemic’s Long-Term Effects Are Uncertain 11
As of November 2021, HHS and FEMA Awarded Over $8 Billion in
COVID-19 Relief Funding for Behavioral Health Mainly through
Existing Programs, Such As Block Grants 25
COVID-19 Relief Funds for Behavioral Health Could Generally
Serve Populations at Higher Risk; Selected Funding Recipients’
Plans for Serving These Populations Varied 40
Agency Comments 50
Appendix I Objectives, Scope, and Methodology 54
Appendix II Other Populations Stakeholders Identified as Potentially Being
at Higher Risk of Behavioral Health Effects 63
Appendix III Challenges in Assessing the COVID-19 Pandemic’s Effects
on Behavioral Health 67
Appendix IV Block Grant Awards Provided from COVID-19 Relief Funds
for Behavioral Health 69
Appendix V Crisis Counseling Assistance and Training Program Awards
for COVID-19 Relief 74
Appendix VI GAO Contact and Staff Acknowledgements 77
Page i GAO-22-104437 Behavioral Health and COVID-19
Tables
Table 1: Department of Health and Human Services Programs or
Activities Related to Behavioral Health Funded Through
the COVID-19 Relief Acts 26
Table 2: Behavioral Health Block Grant Supplemental Funding
from COVID-19 Relief Acts as of November 2021 30
Table 3: COVID-19 Specific Discretionary Grant Programs from
COVID-19 Relief Funding as of November 2021 35
Table 4: COVID-19 Relief Funding for Suicide Prevention
Programs as of November 2021 37
Table 5: Target Population Requirements for Each of the Six
Largest Behavioral Health Programs that Provided
COVID-19 Relief Funding 41
Table 6: Federal Agencies, Health Care Provider Associations,
and Other Organizations That Provided Information about
Behavioral Health during the COVID-19 Pandemic 55
Table 7: Federal COVID-19 Behavioral Health Relief Funding
Recipients Interviewed 57
Table 8: Other Populations Stakeholders Identified as Potentially
Being at Higher Risk of Behavioral Health Effects Related
to the COVID-19 Pandemic 64
Table 9: Challenges in Assessing the COVID-19 Pandemic’s
Effect on Behavioral Health 67
Table 10: Community Mental Health Services Block Grant
(MHBG) Supplemental Award Amounts from COVID-19
Relief Funds by State, U.S. Territory, or Jurisdiction 69
Table 11: Substance Abuse Prevention and Treatment Block
Grant (SABG) Supplemental Award Amounts from
COVID-19 Relief Funds by State, U.S. Territory,
Jurisdiction, or Tribe 71
Table 12: Crisis Counseling Assistance and Training Program
Approved Award Amounts by State and Territory as of
November 2021 74
Figures
Figure 1: Populations That May Be At Higher Risk of Behavioral
Health Effects Related to the COVID-19 Pandemic 12
Figure 2: People from Certain Racial and Ethnic Groups:
Examples of Information about Behavioral Health Risks 14
Page ii GAO-22-104437 Behavioral Health and COVID-19
Figure 3: Health Care Workers: Examples of Information about
Behavioral Health Risks 15
Figure 4: Children and Adolescents: Examples of Information
about Behavioral Health Risks 17
Figure 5: People with Pre-Existing Behavioral Health Conditions:
Examples of Information about Behavioral Health Risks 18
Figure 6: Young Adults: Examples of Information about Behavioral
Health Risks 19
Figure 7: People Facing Financial Distress: Examples of
Information about Behavioral Health Risks 21
Figure 8: Over $8 Billion in COVID-19 Relief Funding Awarded for
Behavioral Health as of November 2021, by Program 28
Figure 9: Location of the Certified Community Behavioral Health
Clinic Expansion Grants Program Grantees Awarded
Funding Provided by the COVID-19 Relief Acts as of
November 2021 32
Figure 10: Examples of How Selected Funding Recipients Have
Used or Planned to Use COVID-19 Relief Funds for
Behavioral Health to Reach Higher-Risk Populations 46
Page iii GAO-22-104437 Behavioral Health and COVID-19
Abbreviations
ARPA American Rescue Plan Act of 2021
CAA Consolidated Appropriations Act, 2021
CCBHC Certified Community Behavioral Health Clinic
CCP Crisis Counseling Assistance and Training Program
CDC Centers for Disease Control and Prevention
COVID-19 Coronavirus Disease 2019
FEMA Federal Emergency Management Agency
GPRA Government Performance and Results Act
HHS Department of Health and Human Services
MHBG Community Mental Health Services Block Grant
SABG Substance Abuse Prevention and Treatment Block Grant
SAMHSA Substance Abuse and Mental Health Services
Administration
SED serious emotional disturbance
SMI serious mental illness
SUD substance use disorder
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Page iv GAO-22-104437 Behavioral Health and COVID-19
Letter
441 G St. N.W.
Washington, DC 20548
December 10, 2021
Congressional Committees
The effects of the Coronavirus Disease 2019 (COVID-19) pandemic and
related economic crisis—such as increased social isolation, stress, and
unemployment—have intensified concerns about the number of people in
the United States affected by behavioral health conditions: mental health
and substance use disorders. 1 Data collected during the COVID-19
pandemic suggest that the pandemic is potentially driving another
national crisis related to its effects on behavioral health, with people
experiencing new or exacerbated behavioral health symptoms or
conditions. 2 For example, from April 2020 through September 2021,
between 29 to 43 percent of U.S. adults reported symptoms of anxiety or
depressive disorder, according to the Census Bureau’s Household Pulse
Survey—percentages considerably higher than the percentage of adults
(11 percent) reporting those symptoms in a similar survey in 2019. 3
Additionally, data suggest that substance use—alcohol and drug use—
has also increased during the pandemic. In particular, in August 2020, the
Centers for Disease Control and Prevention (CDC) published the results
of surveys that found that about 13 percent of overall adult respondents
reported having started or increased substance use to cope with stress or
1We define behavioral health conditions as all mental, emotional, and substance use
disorders that are included in the Diagnostic and Statistical Manual of Mental Disorders.
Examples of mental health conditions that are included are anxiety disorders; mood
disorders, such as depression; post-traumatic stress disorder; and schizophrenia.
Examples of substance use disorders are alcohol use disorder and opioid use disorder.
2In this report, we use the term behavioral health effects to include new or exacerbated
behavioral health symptoms and conditions associated with the pandemic, such as those
related to anxiety, depression, and substance use; behavioral health effects also include
suicidal ideation, suicide attempts, and suicide deaths.
3The Household Pulse Survey, an experimental data product, is an interagency federal
statistical rapid response survey to measure household experiences during the COVID-19
pandemic. The survey is conducted by the Census Bureau in partnership with seven other
agencies from the Federal Statistical System. See appendix I for more information about
the Household Pulse Survey methodology and limitations. Regarding the 2019 survey,
see Centers for Disease Control and Prevention, National Center for Health Statistics,
Estimates of Mental Health Symptomatology, by Month of Interview: United States, 2019
(March 2021).
Page 1 GAO-22-104437 Behavioral Health and COVID-19
emotions related to COVID-19. 4 Moreover, drug overdose deaths
increased about 29 percent from April 2020 to April 2021, to a predicted
record high of 100,306 lives lost, according to provisional data from
CDC’s National Center for Health Statistics. 5
As demand for behavioral health treatment services was expected to
increase as a result of the COVID-19 pandemic, access to treatment was
also expected to worsen. 6 Concerns about the availability of behavioral
health treatment, particularly for low-income individuals, have been
longstanding, as have been concerns about shortages of qualified
behavioral health professionals, particularly in rural areas. 7 The pandemic
has exacerbated these concerns. According to the Substance Abuse and
Mental Health Services Administration (SAMHSA), an agency within the
Department of Health and Human Services (HHS), contributing factors
include layoffs of behavioral health staff and the loss of providers without
the financial reserves to survive long-term. 8
4See M. É. Czeisler, R. I. Lane, E. Petrosky et al., Mental Health, Substance Use, and
Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020,
MMWR Morbidity and Mortality Weekly Report, vol. 69, no. 32 (2020): pp. 1049-1057
(Atlanta, Ga.: Centers for Disease Control and Prevention, Aug. 14, 2020).
5The CDC National Center for Health Statistics provisional counts are often incomplete
and causes of death may be pending investigation resulting in an underestimate relative to
final counts. To address this, CDC adjusted provisional counts for reporting delays by
generating a set of predicted provisional counts.
6See GAO, COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response, GAO-21-191 (Washington, D.C.: Nov. 30, 2020); and Behavioral Health:
Patient Access, Provider Claims Payment, and the Effect of the COVID-19 Pandemic,
GAO-21-437R (Washington, D.C.: Mar. 31, 2021).
7See GAO, Behavioral Health: Options for Low-Income Adults to Receive Treatment in
Selected States, GAO-15-449 (Washington, D.C.: June 19, 2015); and Health Resources
and Services Administration, National Center for Health Workforce Analysis, National
Projections of Supply and Demand for Selected Behavioral Health Practitioners: 2013-
2025 (Rockville, Md.: November 2016). For example, before the COVID-19 pandemic, the
Health Resources and Services Administration reported that by 2025 shortages of seven
selected types of behavioral health providers were expected—with shortages of some
provider types expected to exceed 10,000 full-time equivalents.
8As a result of the COVID-19 pandemic, behavioral health care providers, like other health
care providers, may have experienced financial losses and changes in operating
expenses due to factors such as decreased revenues from cancellations of in-person
visits, limitations in services due to social distancing requirements, and increased
expenses, such as for purchasing personal protective equipment.
Page 2 GAO-22-104437 Behavioral Health and COVID-19
Three COVID-19 relief acts—the CARES Act, the Consolidated
Appropriations Act, 2021 (CAA), and the American Rescue Plan Act of
2021 (ARPA)—specifically appropriated funds for programs and activities
to help address the nation’s behavioral health needs. 9 Most of these
funds were provided to SAMHSA for further distribution through various
grant programs to states and other entities. In addition, on April 28, 2020,
the President granted the Federal Emergency Management Agency
(FEMA) authority to approve the Crisis Counseling Assistance and
Training Program (CCP) for COVID-19 pandemic related disasters. 10
Collectively, in this report we use the term “COVID-19 relief funds for
behavioral health” to refer to funds appropriated to HHS agencies
specifically for behavioral health through the three COVID-19 relief acts,
as well as funds awarded through FEMA’s CCP. 11
The CARES Act includes a provision for GAO to report on its ongoing
monitoring and oversight efforts related to the COVID-19 pandemic. 12 In
this report, we describe
9Pub. L. No. 116-136, div. B., tit. VIII, 134 Stat. 281, 556 (2020); Pub. L. No. 116-260, div.
M, tit. III, 134 Stat. 1182, 1913 (2020); Pub. L. No. 117-2, tit. II, subtit. H, 135 Stat. 4, 45-
48. Unless otherwise stated, references to the CAA in this report refer to Division M of that
act (Coronavirus Response and Relief Supplemental Appropriations Act, 2021).
Behavioral health funds provided for in annual appropriations acts enacted as part of the
CAA were outside the scope of our review.
10The CCP assists individuals and communities in recovering from the psychological
effects of natural and human caused disasters through community-based outreach and
educational services. FEMA awards CCP funding from its Disaster Relief Fund, which
received $97 billion in supplemental appropriations from the CARES Act, CAA, and ARPA.
11In addition, federal agencies, state agencies, tribes, and other recipients of COVID-19
relief funds may have used funds available for a range of response activities to fund
behavioral health activities. These funds were outside the scope of our review. Similarly,
also outside of our scope were additional COVID-19 relief funds that behavioral health
providers may have received, such as funds through HHS’s Provider Relief Fund, which
reimburses eligible providers for health care-related expenses or lost revenues attributable
to COVID-19. For more information about the Provider Relief Fund, see, for example,
GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its Second
Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021).
12Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). We have regularly issued
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Additional Actions Needed to Improve Accountability and Program
Effectiveness of Federal Response, GAO-22-105051 (Washington, D.C.: Oct. 27, 2021).
Our next government-wide report will be issued in January 2022 and will be available on
GAO’s website at https://www.gao.gov/coronavirus. We will continue to monitor behavioral
health funding as part of this ongoing COVID-19 related oversight.
Page 3 GAO-22-104437 Behavioral Health and COVID-19
1. populations that may be at higher risk of behavioral health effects
related to the COVID-19 pandemic;
2. the amount and type of funding the federal government provided in
COVID-19 relief to states, providers, and other organizations to
address behavioral health needs; and
3. whether COVID-19 relief funds for behavioral health could serve
populations that may be at higher risk of behavioral health effects
related to the pandemic, and how selected funding recipients plan on
using relief funds to serve these populations.
To address all three objectives, we interviewed or obtained written
responses from stakeholders representing a range of roles and
perspectives with respect to behavioral health during the COVID-19
pandemic. These stakeholders include federal agency officials and
researchers, as well as representatives from behavioral health care
provider associations, consumer groups, and other organizations.
Additionally, in four selected states (Colorado, Mississippi, New York, and
West Virginia) and Washington, D.C., we interviewed state agencies and
other selected recipients of COVID-19 relief funding for behavioral health.
We selected these states and Washington, D.C., because of their ranking
in behavioral health metrics, such as rates of serious mental illness, and
to reflect variation in the number of COVID-19 cases and deaths as of
February 2021, among other factors.
To identify populations that may be at higher risk of behavioral health
effects related to the COVID-19 pandemic, we reviewed selected
research by federal agencies and other organizations, such as CDC
Morbidity and Mortality Weekly Reports and data from the Census
Bureau’s Household Pulse Survey. We also analyzed information
stakeholders provided about at-risk populations. As part of our analysis,
we considered how many of the stakeholders we interviewed or obtained
written responses from identified various populations as potentially being
at higher risk of experiencing behavioral health effects related to the
COVID-19 pandemic. We also considered the results of selected
research about populations at risk of such behavioral health effects.
To determine the amount and type of COVID-19 relief funding the federal
government provided for behavioral health and whether the funding could
serve higher-risk populations, we reviewed relevant federal laws,
behavioral health related funding opportunity documents, and award data
for COVID-19 relief funds for behavioral health awarded after the CARES
Act was enacted in March 2020 through November 2021. We reviewed
Page 4 GAO-22-104437 Behavioral Health and COVID-19
these documents to determine such things as grant purposes, time
frames, and populations of focus.
To determine the reliability of the data used for our objectives, we
reviewed relevant documentation, requested written information from
knowledgeable officials, and checked for obvious errors, when
appropriate. We determined the data used in this report were sufficiently
reliable for the purpose of addressing all three objectives above. (See
app. I for additional information on our scope and methodology.)
We conducted this performance audit from July 2020 through December
2021 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
Background
Behavioral Health in the Behavioral health conditions affect a substantial number of adults in the
United States United States. In 2019, prior to the pandemic, an estimated 61.2 million
adults (24.5 percent) in the United States had a behavioral health
condition, according to SAMHSA. 13 Behavioral health conditions can be
grouped into mental illnesses and substance use disorders. Examples of
mental illnesses are anxiety disorders; mood disorders, such as
depression; post-traumatic stress disorder; and schizophrenia. Substance
use disorders include alcohol use disorder and illicit drug use disorders,
such as opioid use disorder. SAMHSA reported that in 2019, an
estimated
• 42 million adults had a mental illness and no co-occurring substance
use disorder;
• 9.7 million adults had substance use disorder and no mental illness;
• 9.5 million adults had both a mental illness and a substance use
disorder; and
13See Substance Abuse and Mental Health Services Administration, Key Substance Use
and Mental Health Indicators in the United States: Results from the 2019 National Survey
on Drug Use and Health, (Rockville, Md.: September 2020).
Page 5 GAO-22-104437 Behavioral Health and COVID-19
• 4.5 million adolescents aged 12 to 17 had either a substance use
disorder or a major depressive episode. 14
Behavioral health symptoms and conditions vary in terms of their severity.
For example, people may have symptoms such as distress, anxiety, or
sadness that do not meet the diagnostic criteria for anxiety disorder,
depression, or other conditions. In contrast, SAMHSA estimated that in
2019, 13.1 million adults had a serious mental illness, which is defined as
a mental, behavioral, or emotional disorder that substantially interfered
with or limited one or more major life activities. 15 Additionally, CDC
estimated that in 2019, 2.8 percent of adults experienced severe
symptoms of depression, 4.2 percent experienced moderate symptoms,
and 11.5 percent experienced mild symptoms. 16
Federal data indicate that before the COVID-19 pandemic, the extent of
behavioral health conditions, symptoms, and outcomes varied across
populations. For example, SAMHSA data show that in 2019, young adults
age 18 to 25 reported higher rates of having any mental illness than
adults in older age groups, and women were more likely than men to
report anxiety and depression symptoms in 2019. 17 Other federal data
14SAMHSA classified adults aged 18 or older as having any mental illness if they had any
mental, behavioral, or emotional disorder in the past year of sufficient duration to meet
criteria in the Diagnostic and Statistical Manual of Mental Disorders (excluding
developmental disorders and substance use disorders). See SAMHSA, Key Substance
Use and Mental Health Indicators in the United States: Results from the 2019 National
Survey on Drug Use and Health (2020).
15See SAMHSA, Key Substance Use and Mental Health Indicators in the United States:
Results from the 2019 National Survey on Drug Use and Health (2020).
16See M.A. Villarroel and E.P. Terlizzi, Symptoms of Depression among Adults: United
States, 2019, NCHS Data Brief, no. 379 (Hyattsville, Md.: National Center for Health
Statistics, September 2020).
17See SAMHSA, Key Substance Use and Mental Health Indicators in the United States:
Results from the 2019 National Survey on Drug Use and Health (2020); Villarroel and
Terlizzi, Symptoms of Depression among Adults: United States, 2019 (2020); and E.P.
Terlizzi and M.A. Villarroel, Symptoms of Generalized Anxiety Disorder among Adults:
United States, 2019, NCHS Data Brief, no. 378 (Hyattsville, Md.: National Center for
Health Statistics, September 2020).
Page 6 GAO-22-104437 Behavioral Health and COVID-19
show that from 1999 to 2019, the drug overdose death rate was
consistently higher for men than women. 18
Behavioral Health Risk Many factors can influence a person’s likelihood of developing a
and Protective Factors behavioral health condition. 19 Both the factors that place people at greater
risk and those that act to protect them influence a person’s likelihood of
developing a condition, and people with risk factors will not necessarily
develop a behavioral health condition (see text box).
Overview of Behavioral Health Risk and Protective Factors
What are they?
• Risk factors are characteristics associated with a higher likelihood of developing a behavioral health condition.
• Protective factors are characteristics associated with a lower likelihood of developing a behavioral health condition—or
that reduce a risk factor’s impact.
Key facts
Risk and protective factors can occur at different levels, such as the individual, community, and societal level.
• People can have multiple risk and protective factors, and both types of factors can have a cumulative effect.
• Risk and protective factors can have influence throughout a person’s life; for example, childhood experiences can
affect the likelihood of developing a condition later in life.
Source: GAO summary of Substance Abuse and Mental Health Services Administration information. | GAO-22-104437
The CDC and others have identified a range of behavioral health risk and
protective factors. These include risk and protective factors for behavioral
health conditions generally, as well as those related to specific
populations, conditions, or outcomes. For example, poverty,
unemployment, isolation and loneliness, lack of education or housing,
racial discrimination, poor nutrition, bereavement, and trauma are all
general behavioral health risk factors, while social support and community
18See H. Hedegaard, A.M. Miniño, and M. Warner, Drug Overdose Deaths in the United
States, 1999–2019, NCHS Data Brief, no. 394 (Hyattsville, Md: National Center for Health
Statistics, December 2020).
19See Substance Abuse and Mental Health Services Administration, A Guide to
SAMHSA’s Strategic Prevention Framework (Rockville, Md.: June 2019); and Substance
Abuse and Mental Health Services Administration, Risk and Protective Factors, accessed
August 12, 2021, https://www.samhsa.gov/sites/default/files/20190718-samhsa-risk-
protective-factors.pdf.
Page 7 GAO-22-104437 Behavioral Health and COVID-19
networks are examples of protective factors. 20 For suicide specifically,
mental illness, social isolation, financial problems, job loss, and barriers to
health care are all risk factors, while available physical and mental health
care and connections to family and friends are protective factors. 21
Behavioral Health in Times According to SAMHSA, it is common for people to experience behavioral
of Disaster health effects related to disease outbreaks, natural disasters (e.g.,
hurricanes), and other types of disasters. For example, people may
experience symptoms such as anxiety or sadness after such disasters. 22
Not everyone with symptoms will go on to have a diagnosed condition.
For many people, symptoms will resolve soon after a crisis. However,
other people will have longer-term effects. 23 In addition, some people who
have no symptoms right after a crisis may develop delayed symptoms
later on. 24
Prior research also indicates that certain populations may be at increased
risk for behavioral health effects in times of disasters. For example, health
20See World Health Organization, Prevention of Mental Disorders: Effective Interventions
and Policy Options, Summary Report (Geneva, Switz.: World Health Organization, 2004).
The report noted that there are generic risk and protective factors that are common to
several mental health problems and disorders. For example, poverty and child abuse are
common to depression, anxiety, and substance abuse. In contrast, disease-specific risk
and preventive factors are mainly related to a particular disorder. For example, negative
thinking is specifically related to depression.
21See Centers for Disease Control and Prevention, Suicide Prevention: Risk and
Protective Factors, accessed June 1, 2021,
https://www.cdc.gov/suicide/factors/index.html.
22See D. J. DeWolfe, Training Manual for Mental Health and Human Service Workers in
Major Disasters, HHS Publication no. ADM 90-538, (2nd ed.) (Rockville, Md.: Substance
Abuse and Mental Health Services Administration, 2000); Substance Abuse and Mental
Health Services Administration, Warning Signs and Risk Factors for Emotional Distress,
accessed September 23, 2021,
https://www.samhsa.gov/find-help/disaster-distress-helpline/warning-signs-risk-factors;
and Substance Abuse and Mental Health Services Administration, Survivors of Disasters
Resource Portal, accessed September 23, 2021,
https://www.samhsa.gov/dtac/disaster-survivors.
23See D. J. DeWolfe, Training Manual for Mental Health and Human Service Workers in
Major Disasters (2000); Substance Abuse and Mental Health Services Administration,
Tips for Survivors of a Disaster or Other Traumatic Event: Managing Stress, HHS
Publication No. SMA-13-4776, (Rockville, Md.: SAMHSA, January 2013); and SAMHSA,
Warning Signs and Risk Factors for Emotional Distress.
24See E. Goldmann and S. Galea, “Mental Health Consequences of Disasters,” Annual
Review of Public Health, vol. 35 (2014).
Page 8 GAO-22-104437 Behavioral Health and COVID-19
care workers and surviving patients are at increased risk of behavioral
health effects related to disease outbreaks. 25 Children and adolescents,
older adults, and people with pre-existing behavioral health conditions are
among those generally at risk after disasters, according to SAMHSA. 26
Also, according to a review of disaster mental health research, people
with certain pre-disaster risk factors—such as having a prior mental
illness or being a woman or a child—are at increased risk for behavioral
health effects; post-disaster risk factors include life stressors such as job
loss and disaster-related health concerns, and low social support. 27 A
person’s degree of exposure to a disaster is the most predictive factor
overall, according to the review; exposure to a disaster includes factors
such as experiencing life threats or the death of loved ones, or
responding to emergency situations.
Federal Agencies that Various federal agencies within HHS regularly conduct behavioral health-
Address Behavioral Health related work. In particular, SAMHSA leads federal public health efforts to
advance the behavioral health of the nation. SAMHSA is responsible for,
among other things, providing federal funding through grants to states,
local communities, and private entities to support community-based
mental health and substance abuse treatment and prevention services.
For example, SAMHSA’s two largest grant programs supporting these
treatment and prevention services are the Community Mental Health
Services Block Grant and the Substance Abuse Treatment and
Prevention Block Grant. SAMHSA also conducts surveillance and data
25See G. Salazar de Pablo, J. Vaquerizo-Serrano, A. Catalan et al., “Impact of
Coronavirus Syndromes on Physical and Mental Health of Health Care Workers:
Systematic Review and Meta-Analysis,” Journal of Affective Disorders, vol. 275 (Oct. 1,
2020); S. W. H. Chau, O. W. H. Wong, R. Ramakrishnan et al., “History for Some or
Lesson for All? A Systematic Review and Meta-analysis on the Immediate and Long-Term
Mental Health Impact of the 2002–2003 Severe Acute Respiratory Syndrome (SARS)
Outbreak,” BMC Public Health, vol. 21, no. 1 (April 7, 2021); and J. M. Cénata, N. Felix, C.
Blais-Rochette et al., “Prevalence of Mental Health Problems in Populations Affected by
the Ebola Virus Disease: A Systematic Review and Meta-Analysis,” Psychiatry Research,
vol. 289 (July 2020).
26Examples of other at-risk groups include women, people who are homeless, and first
responders and recovery workers who respond to crisis situations. See SAMHSA,
Warning Signs and Risk Factors for Emotional Distress.
27See E. Goldmann and S. Galea, “Mental Health Consequences of Disasters,” Annual
Review of Public Health, vol. 35 (2014). According to this review, pre-disaster mental
illness is consistently associated with post-disaster depression, post-traumatic stress
disorder, and substance use disorders. Children exposed to disasters are particularly
vulnerable to psychological problems, which are most commonly symptoms of anxiety (for
example, panic and phobias) and depression.
Page 9 GAO-22-104437 Behavioral Health and COVID-19
collection of national behavioral health issues and provides statistical and
analytic support to grantees.
Other HHS agencies are regularly involved in behavioral health-related
work. Some of these agencies and selected behavioral health-related
activities include:
• CDC, which conducts surveillance and nationwide data collection of
behavioral health-related deaths (such as suicide deaths and drug
overdose deaths);
• National Institutes of Health, which provides funding for and conducts
research on behavioral health topics, such as mental health disorders
and substance use and addiction; and
• Health Resources and Services Administration, which collects data on
behavioral health workforce shortage areas and provides funding to
support behavioral health workforce training.
Further, in times of disasters or emergencies, such as the COVID-19
pandemic, additional federal agencies may take on roles to help address
behavioral health issues. This includes FEMA, within the Department of
Homeland Security, which funds and implements the CCP. When states,
territories, or tribal governments request major disaster declarations from
the President, they may request assistance under this program. Likewise,
when the President declares a major disaster, the declaration may
authorize FEMA’s Individual Assistance programs, which may include the
CCP. 28
28FEMA’s Individual Assistance mission is to ensure disaster survivors have timely access
to a full range of authorized programs and services to maximize recovery.
Page 10 GAO-22-104437 Behavioral Health and COVID-19
Certain Populations,
Such As People from
Certain Racial and
Ethnic Groups, May
Be at Higher Risk of
Behavioral Health
Effects; Pandemic’s
Long-Term Effects
Are Uncertain
People from Certain COVID-19 has had widespread repercussions for the behavioral health of
Racial and Ethnic Groups, the nation as a whole, but certain populations may be at higher risk of
behavioral health effects, according to 32 stakeholders we interviewed
Children and Adolescents, and our review of selected research. 29 We found that the populations
and Others May Be At identified by stakeholders and research as potentially at higher risk
Higher Risk of New or generally fell into two groups: (1) six populations most frequently
Worsening Behavioral identified by stakeholders, and (2) 11 other populations stakeholders
Health Conditions or identified. 30 (See fig. 1.)
Symptoms
29In this report, we use the term behavioral health effects to refer to new or exacerbated
behavioral health symptoms and conditions associated with the pandemic, such as those
related to anxiety, depression, and substance use; behavioral health effects also include
suicidal ideation, suicide attempts, and suicide deaths. This analysis was based on 32 of
the stakeholders we interviewed or obtained written responses from. We did not include
responses from officials of two federal agencies, because they did not provide input on
populations at higher risk of behavioral health effects. We also did not include responses
from the recipients of federal COVID-19 behavioral health relief funding that were not state
agencies.
30We considered how many of the stakeholders identified various populations as
potentially being at higher risk of experiencing behavioral health effects related to the
COVID-19 pandemic. The six populations stakeholders identified most frequently included
four populations identified by more than half of the 32 stakeholders, and two populations
identified by about half (15 or 16) of stakeholders. A smaller share of stakeholders (three
to nine) also identified 11 additional populations as potentially at higher risk.
Page 11 GAO-22-104437 Behavioral Health and COVID-19
Figure 1: Populations That May Be At Higher Risk of Behavioral Health Effects
Related to the COVID-19 Pandemic
Note: We use the term behavioral health effects to refer to new or exacerbated behavioral health
symptoms and conditions associated with the pandemic, such as those related to anxiety,
depression, and substance use; behavioral health effects also include suicidal ideation, suicide
attempts, and suicide deaths. People in one or more higher-risk populations will not necessarily
develop behavioral health symptoms or conditions. Our analysis was based on interviews and written
responses from 32 stakeholders, including federal officials, state officials, researchers, and others.
We considered how many of these stakeholders identified populations as potentially being at higher
risk of behavioral health effects.
There are a range of reasons why these populations might be at higher
risk, according to stakeholders and research. For example, the pandemic
disrupted access to school-based behavioral health supports for children
and adolescents, and people with pre-existing behavioral health
conditions faced reduced access to residential programs and other forms
of in-person care, some stakeholders said. Some stakeholders also noted
that health care workers have faced heightened health risks and stress
due to the pandemic. Also, several populations, such as adolescents and
young adults, had increasing or relatively higher rates of behavioral health
conditions prior to the pandemic. 31
31See SAMHSA, Key Substance Use and Mental Health Indicators in the United States:
Results from the 2019 National Survey on Drug Use and Health (2020); and Centers for
Disease Control and Prevention, Youth Risk Behavior Survey Data Summary & Trends
Report 2009-2019 (Atlanta, Ga.: 2021).
Page 12 GAO-22-104437 Behavioral Health and COVID-19
People from certain racial and ethnic groups. Twenty-two
stakeholders shared concerns about the pandemic’s potential impact on
the behavioral health of people from certain racial and ethnic groups. 32
Some stakeholders cited the pandemic’s disproportionate effect on
certain racial and ethnic groups with respect to illness and death. 33
Between March 2020 and August 2021, for example, available CDC data
indicate that non-Hispanic American Indian/Alaska Native individuals
were hospitalized due to COVID-19 at a rate 3.5 times that of non-
Hispanic White individuals, after adjusting for age; Hispanic or Latino and
non-Hispanic Black individuals were hospitalized at a rate 2.8 times that
of non-Hispanic White individuals. 34 Some stakeholders said that
disparities in access to behavioral health care could contribute to higher
risk for people from certain racial and ethnic groups, as could the
pandemic’s impact on employment. We have reported that during the
pandemic, labor market conditions weakened more for Hispanic or Latino,
Black, and Asian individuals as compared to White individuals. 35 See
figure 2 for examples of information from stakeholders and research.
32For the purposes of this report, “people from certain racial and ethnic groups” refers to
people of races and ethnicities other than non-Hispanic White, including people who
identify as multiracial. People of races and ethnicities other than non-Hispanic White have
a wide variety of backgrounds and experiences.
33We have reported on the racial and ethnic disparities in COVID-19 cases,
hospitalizations, and deaths, as well as vaccination rates. See GAO, Health Care
Capsule: Racial and Ethnic Disparities, GAO-21-105354 (Washington, D.C.: Sept. 23,
2021); and GAO-21-387.
34During that time frame, non-Hispanic American Indian/Alaska Native individuals died of
COVID-19 at a rate 2.4 times that of non-Hispanic White individuals; Hispanic or Latino
individuals died of COVID-19 at a rate 2.3 times that of non-Hispanic White individuals;
and non-Hispanic Black individuals died at a rate two times that of non-Hispanic White
individuals, after adjusting for age. Hospitalization rates are based on COVID-NET, a CDC
surveillance system that collects data on COVID-19-associated hospitalizations confirmed
by laboratory testing, in select counties in 14 states representing about 10 percent of the
U.S. population. See Centers for Disease Control and Prevention, Risk for COVID-19
Infection, Hospitalization, and Death By Race/Ethnicity, accessed October 4, 2021,
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitaliz
ation-death-by-race-ethnicity.html#print.
35See GAO-21-387.
Page 13 GAO-22-104437 Behavioral Health and COVID-19
Figure 2: People from Certain Racial and Ethnic Groups: Examples of Information about Behavioral Health Risks
a
Substance Abuse and Mental Health Services Administration, Double Jeopardy: COVID-19 and
Behavioral Health Disparities for Black and Latino Communities in the U.S. (Rockville, Md.: 2020).
b
Substance Abuse and Mental Health Services Administration, Behavioral Health Barometer: United
States, Volume 6: Indicators as Measured Through the 2019 National Survey on Drug Use and
Health and the National Survey of Substance Abuse Treatment Services, HHS Publication no.
PEP20-07-02-001 (Rockville, Md.: 2020).
c
The Household Pulse Survey, an experimental data product, is an interagency federal statistical
rapid response survey to measure household experiences during the COVID-19 pandemic. These
estimates are based on responses to two questions about symptoms of depressive disorder and two
questions about symptoms of anxiety disorder in the prior 7 days. The percentage of adults include
those who reported symptoms that generally occurred more than half the days or nearly every day.
The margin of error for these estimates varied, but ranged from about ± 1 to 4 percentage points at
the 95 percent confidence level. See appendix I for details on the Household Pulse Survey and these
estimates, including response rates and nonresponse bias analysis.
d
N. Panchal, R. Garfield, C. Cox et al. Substance Use Issues Are Worsening Alongside Access to
Care (San Francisco, Ca.: Kaiser Family Foundation, Aug. 12, 2021), accessed October 5, 2021,
https://www.kff.org/policy-watch/substance-use-issues-are-worsening-alongside-access-to-care. The
analysis was based on Centers for Disease Control and Prevention drug overdose death data,
including provisional data for 2020, and Census Bureau population estimates.
Page 14 GAO-22-104437 Behavioral Health and COVID-19
e
National Institutes of Health officials cited T. O. Mitchell and L. Li, “State-Level Data on Suicide
Mortality During COVID-19 Quarantine: Early Evidence of a Disproportionate Impact on Racial
Minorities,” Psychiatry Research, vol. 295 (2021).
Health care workers. Twenty-two stakeholders raised concerns about
behavioral health risks to health care workers. Multiple stakeholders cited
a range of factors that could adversely affect these workers’ behavioral
health, such as the fear of contracting COVID-19 or transmitting it to
family members, exhaustion, burnout, and losing patients due to COVID-
19. See figure 3 for examples of information from stakeholders and
research.
Figure 3: Health Care Workers: Examples of Information about Behavioral Health Risks
a
National Academies of Sciences, Engineering, and Medicine, Rapid Expert Consultation on
Understanding Causes of Health Care Worker Deaths Due to the COVID-19 Pandemic (December
10, 2020) (Washington, D.C.: The National Academies Press, 2020).
b
S. W. H. Chau, O. W. H. Wong, R. Ramakrishnan et al., “History for Some or Lesson for All? A
Systematic Review and Meta-analysis on the Immediate and Long-Term Mental Health Impact of the
2002–2003 Severe Acute Respiratory Syndrome (SARS) Outbreak,” BMC Public Health, vol. 21, no.
1 (April 7, 2021); J. M. Cénata, N. Felix, C. Blais-Rochette et al., “Prevalence of Mental Health
Problems in Populations Affected by the Ebola Virus Disease: A Systematic Review and Meta-
Page 15 GAO-22-104437 Behavioral Health and COVID-19
Analysis,” Psychiatry Research, vol. 289 (July 2020); and G. Salazar de Pablo, J. Vaquerizo-Serrano,
A. Catalan et al. “Impact of Coronavirus Syndromes on Physical and Mental Health of Health Care
Workers: Systematic Review and Meta-Analysis,” Journal of Affective Disorders, vol. 275 (Oct. 1,
2020).
c
Attributed to Dr. Albert Wu, Johns Hopkins University. See National Academies of Sciences,
Engineering, and Medicine, Mental Health and Substance Use Disorders in the Era of COVID-19: The
Impact of the Pandemic on Communities of Color: Proceedings of a Workshop in Brief (Washington,
D.C.: The National Academies Press, March 2021).
d
Substance Abuse and Mental Health Services Administration, Disaster Technical Assistance Center
Supplemental Research Bulletin: A Preliminary Look at the Mental Health and Substance Use-related
Effects of the COVID-19 Pandemic, (Rockville, Md.: May 2021); and R. Hennein and S. Lowe, “A
Hybrid Inductive-Abductive Analysis of Health Workers’ Experiences and Wellbeing During the
COVID-19 Pandemic in the United States,” PLoS ONE, vol. 15, no. 10 (2020).
Children and adolescents. Nineteen stakeholders raised concerns
about the pandemic’s effects on children and adolescents. Their concerns
stemmed from a range of factors. For example, some stakeholders noted
that school closures had adversely affected children’s and adolescents’
ability to connect with their peers, as well as their access to school-based
supports, such as behavioral health screening and services and adults
who could identify potential abuse and neglect. Some stakeholders noted
that children’s and adolescents’ well-being can be affected by their homes
and communities. Negative experiences that may occur due to the
pandemic, such as parental substance use, financial hardship, and food
insecurity, can put them at risk for behavioral health conditions in the
short-term and into adulthood. 36 See figure 4 for examples of information
from stakeholders and research.
36See CDC, Adverse Childhood Experiences Prevention Strategy (Atlanta, Ga.: 2021).
Page 16 GAO-22-104437 Behavioral Health and COVID-19
Figure 4: Children and Adolescents: Examples of Information about Behavioral Health Risks
a
Centers for Disease Control and Prevention, Youth Risk Behavior Survey Data Summary & Trends
Report 2009-2019, accessed October 25, 2021, http://www.cdc.gov/YRBSS.
b
Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental
Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and
Health, (Rockville, Md.: September 2020); and H. Hedegaard, S.C. Curtin, and M. Warner, Suicide
Mortality in the United States, 1999–2019, NCHS Data Brief, no 398 (Hyattsville, Md.: National Center
for Health Statistics, February 2021).
c
J. V. Verlenden, S. Pampati, C.N. Rasberry et al., Association of Children’s Mode of School
Instruction with Child and Parent Experiences and Well-Being During the COVID-19 Pandemic—
COVID Experiences Survey, United States, October 8–November 13, 2020, MMWR Morbidity and
Mortality Weekly Report, vol.70, no.11 (Atlanta, Ga.: Centers for Disease Control and Prevention,
Mar. 19, 2021).
d
E. Yard, L. Radhakrishnan, M. F. 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, MMWR Morbidity and Mortality Weekly Report, vol. 70, no.
24 (2021) (Atlanta, Ga: Centers for Disease Control and Prevention, June 18, 2021).
e
S.D. Hillis, H.J.T. Unwin, Y. Chen et al., “Global Minimum Estimates of Children Affected by COVID-
19-Associated Orphanhood and Deaths of Caregivers: A Modelling Study,” The Lancet, vol. 398
(2021).
Page 17 GAO-22-104437 Behavioral Health and COVID-19
People with pre-existing behavioral health conditions. Nineteen
stakeholders identified people with substance use disorder, serious
mental illness, or other pre-existing behavioral health conditions as
potentially at higher risk of behavioral health effects due to the pandemic.
Pandemic-related factors, such as social isolation, increased stress, and
unemployment, can worsen existing behavioral health conditions or lead
to relapse among people in recovery for alcohol use disorder and other
substance use disorders, according to stakeholders. In addition, the
pandemic created challenges accessing care, such as the inability to
have in-person contact with groups or treatment providers, and reduced
access to residential programs due to social distancing measures, some
stakeholders said. Further, telehealth—services provided remotely via
technology—might not be a viable or preferred option for some people
with pre-existing conditions, some stakeholders said. See figure 5 for
examples of information from stakeholders and research.
Figure 5: People with Pre-Existing Behavioral Health Conditions: Examples of Information about Behavioral Health Risks
Page 18 GAO-22-104437 Behavioral Health and COVID-19
a
Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental
Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and
Health, (Rockville, Md.: September 2020).
b
Centers for Disease Control and Prevention, Suicide Prevention: Risk and Protective Factors,
accessed June 1, 2021, https://www.cdc.gov/suicide/factors/index.html.
c
M. É. Czeisler, R. I. Lane, E. Petrosky et al., Mental Health, Substance Use, and Suicidal Ideation
During the COVID-19 Pandemic — United States, June 24–30, 2020, MMWR Morbidity and Mortality
Weekly Report, vol. 69, no. 32 (2020): pp. 1049-1057 (Atlanta, Ga.: Centers for Disease Control and
Prevention, Aug. 14, 2020).
Young adults. Sixteen stakeholders raised concerns about young adults.
Some stakeholders cited factors such as young adults’ relatively higher
rates of social isolation and loneliness before the pandemic, as well as
the increases in social isolation and employment challenges due to the
pandemic. See figure 6 for examples of information from stakeholders
and research.
Figure 6: Young Adults: Examples of Information about Behavioral Health Risks
Note: The different young adult age ranges shown above reflect the varying age categories cited in
selected research.
Page 19 GAO-22-104437 Behavioral Health and COVID-19
a
Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental
Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and
Health, (Rockville, Md.: September 2020).
b
B. Shovestul, J. Han, L. Germine et al. “Risk Factors for Loneliness: The High Relative Importance of
Age Versus Other Factors,” PLoS ONE, vol.15, no. 2 (2020); N. Leigh-Hunt N, 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 (2017); and National Academies of Sciences, Engineering,
and Medicine, Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care
System, (The National Academies Press; Washington, D.C.: 2020).
c
The Household Pulse Survey, an experimental data product, is an interagency federal statistical
rapid response survey to measure household experiences during the COVID-19 pandemic. These
estimates are based on responses to two questions about symptoms of depressive disorder and two
questions about symptoms of anxiety disorder in the prior 7 days. The percentage of adults include
those who reported symptoms that generally occurred more than half the days or nearly every day.
These estimates have a margin of error of about ± 2 percentage points at the 95 percent confidence
level. See appendix I for details on the Household Pulse Survey and these estimates, including
response rates and nonresponse bias analysis.
d
M. É. Czeisler, R. I. Lane, E. Petrosky et al., Mental Health, Substance Use, and Suicidal Ideation
During the COVID-19 Pandemic — United States, June 24–30, 2020, MMWR Morbidity and Mortality
Weekly Report, vol. 69, no. 32 (2020): p. 1049-1057 (Atlanta, Ga.: Centers for Disease Control and
Prevention, Aug. 14, 2020).
e
Substance Abuse and Mental Health Services Administration, Disaster Technical Assistance Center
Supplemental Research Bulletin: A Preliminary Look at the Mental Health and Substance Use-related
Effects of the COVID-19 Pandemic, (Rockville, Md.: May 2021).
People facing financial distress. Fourteen stakeholders identified
people experiencing financial distress as potentially at higher risk. We
include in this population people experiencing unemployment, housing or
food insecurity, low incomes, or other situations related to financial
distress. Some stakeholders noted that job loss, being homeless, not
having enough food, and other financial difficulties can adversely affect
behavioral health. See figure 7 for examples of information from
stakeholders and research.
Page 20 GAO-22-104437 Behavioral Health and COVID-19
Figure 7: People Facing Financial Distress: Examples of Information about Behavioral Health Risks
a
Centers for Disease Control and Prevention, Suicide Prevention: Risk and Protective Factors,
accessed June 1, 2021, https://www.cdc.gov/suicide/factors/index.html.
b
C. K. Ettman, S. M. Abdalla, G. H. Cohen et al., “Prevalence of Depression Symptoms in US Adults
Before and During the COVID-19 Pandemic,” JAMA Network Open, vol. 3, no. 9 (2020).
c
E. E. McGinty, R. Presskreischer, K.E. Anderson et al. “Psychological Distress and COVID-19-
Related Stressors Reported in a Longitudinal Cohort of U.S. Adults in April and July 2020,” JAMA,
vol. 324 no. 24 (2020).
Page 21 GAO-22-104437 Behavioral Health and COVID-19
A smaller share of stakeholders we interviewed, and selected research,
Other Populations Stakeholders Identified
As At Risk for Behavioral Health Effects identified other populations that may also be at higher risk of behavioral
• Women
health effects due to the pandemic. 37 These 11 populations could be at
• Older adults higher risk for a range of reasons, according to stakeholders. For
• Parents of young or school-aged children example, some populations’ occupations or roles put them at risk, such
• People who were diagnosed with COVID-19 as essential workers and parents of young or school-aged children. Other
• Essential workers populations—such as people with fewer social supports and people
• Individuals who are lesbian, gay, bisexual, experiencing domestic violence—were at higher risk of behavioral health
or transgender
• People with fewer social supports
conditions prior to the pandemic and could experience exacerbated
• People experiencing domestic violence conditions, according to some stakeholders. People diagnosed with
• People living in rural areas COVID-19 might be at higher risk, according to multiple stakeholders;
• Unpaid caregivers of adults however, some stakeholders said it was too early to know what the
• People with limited education implications of a COVID-19 diagnosis were for behavioral health. See
Source: GAO analysis of stakeholder input and selected
research. | GAO-22-104437
appendix II for information about behavioral health risks for these
populations.
Some people’s characteristics or circumstances may include them in
more than one of the higher-risk populations described above, which may
Observations From a Physician Who lead to compounding behavioral health risks for them. For example,
Treats Hospitalized Patients
people from certain racial and ethnic groups are more likely than non-
We spoke with a physician-researcher who
was concerned about the behavioral health of Hispanic White individuals to work in industries that have been
people of races and ethnicities other than particularly at risk for loss of income during the pandemic, such as retail
White, particularly in communities with many and hospitality; this places some individuals in two higher-risk groups:
COVID-19 deaths. He said the pandemic has
combined economic uncertainty; grief and people from certain racial and ethnic groups, and people facing financial
loss; and health-related fears—and he sees distress. 38 Health care workers may be at higher risk due not only to their
patients “who are facing all of these issues at
once.” He described, for example, a 23-year- profession, but also if they are in other higher-risk groups, such as
old patient who was hospitalized for a chronic parents of young or school-aged children, women, or people from certain
medical condition. The patient had lost
multiple family members due to COVID-19,
racial and ethnic groups. Members of American Indian/Alaska Native
including his mother and uncle. The patient’s communities may also be at higher risk due to a combination of factors
two self-reported symptoms were pain and (see text box). Nonetheless, people in one or more higher-risk population
depression.
Source: GAO summary of stakeholder input. |
will not necessarily develop behavioral health symptoms or conditions, as
GAO-22-104437 protective factors can mitigate the behavioral health risks they face.
37These populations are not meant to be exhaustive of all other populations potentially at
higher risk of behavioral health effects due to the pandemic, but reflect stakeholder input
we received and selected research we reviewed. There may be other populations also at
higher risk that our stakeholders did not identify.
38See Substance Abuse and Mental Health Services Administration, Double Jeopardy:
COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S.
(Rockville, Md.: 2020).
Page 22 GAO-22-104437 Behavioral Health and COVID-19
American Indians/Alaska Natives: Observations on Pandemic-Related Behavioral Health Risks
We spoke with some tribal organizations about the experiences of American Indians/Alaska Natives during the pandemic and
factors that may put them at higher risk of behavioral health effects. An official from one tribe explained the multiple risk factors
converging for that tribe:
The tribal official told us that financial stability decreased, the removal of free and reduced cost school lunch most children
received led to food insecurity, and social networks were removed as people were remanded to their homes. He also noted that
the tribe’s reservation is rural and remote, with limited telephone and internet services, creating challenges for implementing
telehealth during the pandemic. He said that these challenges made it difficult for tribal members to work from home, saying
that many were sent home to do nothing—due to lack of equipment or broadband internet access—which led to major
depressive episodes and increased substance use. He expressed concern that lifetime mental health and substance use
disorder problems could result from the pandemic—noting that the tribe already had substance use problems and COVID-19
only made things worse.
Source: GAO summary of stakeholder input. | GAO-22-104437
Pandemic’s Long-Term The COVID-19 pandemic is ongoing as of this report and it will take time
Effects on Various to determine how different populations may be affected in the long-term,
multiple stakeholders said. Some stakeholders noted that emerging
Populations’ Behavioral
COVID-19 variants, such as Delta, and changes in COVID-19 case
Health Are Unknown numbers, vaccination rates, and the job market create a dynamic
situation. 39 Multiple stakeholders said there is uncertainty about how
Social Isolation and Behavioral Health different populations may fare and whether new higher-risk populations
A researcher who studies social isolation and might emerge over time. Officials from one state, for example, said that
loneliness told us that prior to the COVID-19
pandemic, social isolation and loneliness
new populations of people who had not previously sought behavioral
were linked to poorer behavioral health health services might find they need help due to anxiety, depression,
outcomes, such as depression and anxiety, mood disorders, or post-traumatic stress disorder. Some stakeholders
as well as dementia and other types of
cognitive decline. noted that the pandemic is unprecedented due to its duration, widespread
Pre-pandemic, certain populations reported economic impact, periods of isolation, and other factors. Social isolation
relatively higher rates of social isolation and on such a large scale was an unprecedented aspect of the pandemic and
loneliness, this researcher said. These
populations included, for example, young questions remain about its long-term implications for behavioral health,
adults; people with mental or physical according to some stakeholders. In addition, some stakeholders noted
conditions; people with lower income, less
education, or who were unemployed; and
that as with prior crises, they expect some people will see their behavioral
people with disabilities. health symptoms resolve, others will have persistent effects, and still
Social connection, on the other hand, can others will find that new symptoms or conditions manifest over time. As a
serve as a protective factor that protects result, it will take time to determine the long-term behavioral health effects
against poor behavioral health outcomes.
Source: GAO summary of stakeholder input. | resulting from the pandemic.
GAO-22-104437
39As of November 30, 2021, the Department of Health and Human Services had
characterized two of the COVID-19 variants—Delta and Omicron—as public health
concerns. As of the week ending November 13, 2021, the proportion of current cases
attributed to the Delta variant was estimated to be greater than 99 percent nationally,
according to CDC. CDC reported that the Delta variant is more than twice as contagious
as previous variants.
Page 23 GAO-22-104437 Behavioral Health and COVID-19
Multiple stakeholders also said they did not have a complete picture of
how different populations have been affected during the pandemic. They
cited a range of data gaps and other limitations that led to challenges in
assessing the pandemic’s effects on behavioral health. Some challenges,
such as pandemic-driven changes in data collection methods, stemmed
from the pandemic itself. Other challenges pertained more broadly to
assessments of behavioral health, regardless of the pandemic. For
example, National Institutes of Health officials said a key challenge during
the pandemic stemmed from studies having to pivot to collect data in
ways that were in line with public health mitigation efforts. They stated
that researchers moved from collecting data in-person to collecting it
remotely, typically through online platforms. This presented a new
challenge in reaching people with little or no internet access. SAMHSA
has noted that studies based on surveys of self-reported symptoms do
not reflect whether a respondent meets the diagnostic criteria for a
behavioral health condition, which requires a more thorough assessment.
In addition, National Institutes of Health officials told us that data on
suicides often lag due to the time needed to adjudicate cause of death,
and that those data lags had been exacerbated by competing demands
for medical examiners to determine COVID-19 related deaths. Also, some
stakeholders noted that during the pandemic there have been additional
factors that have potentially affected peoples’ behavioral health, such as
wildfires and the political climate; this makes it difficult to distinguish the
pandemic’s impact from the impact of other factors, according to some
researchers.
Moving forward, multiple stakeholders emphasized the importance of data
collection and research to assess the pandemic’s ongoing effects on
behavioral health. CDC officials, for example, added questions to the
National Health Interview Survey in 2020 to identify people who had been
diagnosed with COVID-19; the survey would help provide information
related to the behavioral health of those diagnosed with COVID-19,
officials said. The National Institutes of Health has funded a range of
efforts to determine how the pandemic is affecting behavioral health.
SAMHSA officials told us that they plan to publish additional information
in 2022 to help inform mental health professionals about what new
research is finding about the pandemic’s effect on behavioral health.
Page 24 GAO-22-104437 Behavioral Health and COVID-19
As of November
2021, HHS and
FEMA Awarded Over
$8 Billion in COVID-
19 Relief Funding for
Behavioral Health
Mainly through
Existing Programs,
Such As Block Grants
Most COVID-19 Relief Based on our review of the three relevant COVID-19 relief acts, funding
Funding for Behavioral documentation, and award data, as of November 2021, the federal
government awarded over $8 billion in COVID-19 relief funding for
Health Was Awarded to
behavioral health. The three relief acts appropriated about $8.56 billion to
States and Community- HHS agencies for behavioral health related grant programs or activities
Based Providers through specified in the acts; of that amount, about $8.24 billion was appropriated
Four Existing and Two to SAMHSA. 40 (See table 1.) This funding was in addition to regular
New Programs annual appropriations for SAMHSA in fiscal years 2020 and 2021, which
were about $5.74 billion and $5.87 billion, respectively.
40SAMHSA officials said that oversight of COVID-19 relief funds for behavioral health
would be conducted in the same way SAMHSA oversees its other grant programs,
including activities such as onsite and virtual financial and compliance reviews, required
annual financial reporting, and submission of periodic performance and progress reports.
SAMHSA’s oversight of COVID-19 relief funds was outside the scope of this review.
Page 25 GAO-22-104437 Behavioral Health and COVID-19
Table 1: Department of Health and Human Services Programs or Activities Related to Behavioral Health Funded Through the
COVID-19 Relief Acts
Appropriations dollars in millions
CARES Acta Consolidated Total
(enacted Appropriations Act, 2021 American Rescue Plan appropriated
March 27, (CAA)b Act of 2021 (ARPA)c by program or
Program or activity 2020) (enacted December 27, 2020) (enacted March 11, 2021) activity
Substance Abuse Prevention and — 1,650 1,500 3,150
Treatment Block Grant
Community Mental Health Services Block — 1,650d 1,500 3,150
Grant
Certified Community Behavioral Health 250e 600f 420 1,270
Clinic Expansion Grants program
Grants to address emergency substance 100e 240f — 340
abuse or mental health needs in local
communitiesg
Suicide prevention programs 50e 50f 20h 120
Behavioral health workforce education — — 100 100
and training grants
Project AWAREi — 50 30 80
Mental and substance use disorder — — 80 80
training for health care professionals,
paraprofessionals, and public safety
officers
Pediatric mental health care access — — 80 80
grants
Community-based funding for local — — 50 50
behavioral health needs
Grants for health care providers to — — 40 40
promote mental health among their
health professional workforce
Community-based funding for local — — 30 30
substance use disorder services
National Child Traumatic Stress Network — 10 10 20
Education and awareness campaign — — 20 20
encouraging healthy work conditions and
use of mental health and substance use
disorder services by health care
professionals
Tribes, tribal organizations, urban Indian 15 — — 15
health organizations, or health or
behavioral health service providers to
tribes
Totals 425j 4,250 3,880 8,555j
Source: GAO analysis of the CARES Act, CAA, and ARPA. | GAO-22-104437
Page 26 GAO-22-104437 Behavioral Health and COVID-19
Notes: A dash (—) reflects that no funding was appropriated for this program or activity in the relevant
COVID-19 relief act. In addition to the funds noted in this table, federal agencies may have used
COVID-19 relief funds available for a range of response activities to fund behavioral health activities.
a
Pub. L. No. 116-136, div. B., tit. VIII, 134 Stat. 281, 556 (2020).
b
Pub. L. No. 116-260, div. M, tit. III, 134 Stat. 1182, 1913 (2020). This table includes relevant
appropriations from Division M of the CAA (Coronavirus Response and Relief Supplemental
Appropriations Act, 2021) and does not include behavioral health funds provided for in annual
appropriations acts enacted as part of the CAA. The CAA specified that from the amounts noted in
this table, a total of not less than $125 million shall be allocated to tribes, tribal organizations, urban
Indian health organizations, or health or behavioral health service providers to tribes. The act also
noted that the Substance Abuse and Mental Health Services Administration (SAMHSA) shall maintain
the 20 percent set-aside for prevention, but may waive requirements with respect to allowable
activities, timelines, or reporting requirements for the Substance Abuse Prevention and Treatment
Block Grant and the Community Mental Health Services Block Grant as deemed necessary to
facilitate a grantee’s response to coronavirus.
c
Pub. L. No. 117-2, tit. II, subtit. H, 135 Stat. 4, 45-48.
d
The CAA specified, that of this amount, SAMHSA was to provide no less than 50 percent directly to
community mental health centers.
e
The CARES Act specified that at least the amount noted be available for this purpose.
f
The CAA specified that at least the amount noted be available for this purpose.
g
Appropriations are for activities under section 501(o) of the Public Health Service Act, which
authorizes noncompetitive grants, contracts, or cooperative agreements to public entities to address
emergency substance abuse or mental health needs in local communities.
h
ARPA funding related to suicide prevention was designated specifically for youth suicide prevention.
The full name of this program is Project AWARE (Advancing Wellness and Resiliency in Education).
i
j
Total does not equal the sum of the numbers listed above, because $10 million of the $425 million in
funding appropriated to SAMHSA in the CARES Act was not designated for a specific program or
activity.
In addition to the $8.56 billion appropriated to SAMHSA and other HHS
agencies, as of November 2021, FEMA has awarded approximately $467
million in COVID-19 relief funding for behavioral health through its CCP.
Of the over $8 billion of the COVID-19 relief funding for behavioral health
that had been awarded as of November 2021, we found that the majority
(over 97 percent) was awarded through six programs, as shown in figure
8:
• the Community Mental Health Services Block Grant,
• the Substance Abuse Prevention and Treatment Block Grant,
• the Certified Community Behavioral Health Clinic (CCBHC) Expansion
Grants program,
• FEMA’s CCP,
• the Community Mental Health Centers Grant Program, and
• the Emergency Grants to Address Mental and Substance Use
Disorders During COVID-19.
Page 27 GAO-22-104437 Behavioral Health and COVID-19
Two of these six programs—the Community Mental Health Centers Grant
Program, and the Emergency Grants to Address Mental and Substance
Use Disorders During COVID-19—were created specifically to respond to
the pandemic, while the other four programs pre-dated the pandemic. The
six programs provide funding to entities such as state agencies and
community behavioral health and mental health centers to, for example,
provide behavioral health services directly to persons in need.
Figure 8: Over $8 Billion in COVID-19 Relief Funding Awarded for Behavioral Health
as of November 2021, by Program
a
This total includes $4 million that the Centers for Disease Control and Prevention obligated for a
national evidence-based campaign related to the prevention of mental health conditions and
substance use disorders.
SAMHSA administers five of these six programs; FEMA administers the
sixth—the CCP—in partnership with SAMHSA. Specific characteristics of
the programs, including eligible funding recipients, award amounts, and
Page 28 GAO-22-104437 Behavioral Health and COVID-19
the ways in which SAMHSA and FEMA awarded funds, varied by
program, as described below.
Community mental health and substance abuse block grant
supplements. The COVID-19 relief acts appropriated about $5.5 billion
as supplemental funding to the existing Community Mental Health
Services Block Grant and the Substance Abuse Prevention and
Treatment Block Grant. As of November 2021, SAMHSA had awarded
$5.325 billion through both block grants to states, Washington, D.C., U.S.
territories, and other jurisdictions using an existing formula specified in
statute to distribute funding to grantees. 41 These grantees may, in turn,
distribute funds to local government entities and nonprofit organizations in
accordance with a plan submitted to SAMHSA. See table 2 for summary
information about awards made through the two grant programs; see
appendix IV for a complete list of award amounts, including per capita
amounts, by grantee.
41SAMHSA also awarded the substance abuse block grant to one tribe. The formula takes
into account three measures: (1) the population in need of services (adults aged 18-64 in
the state), (2) costs of services in the state, and (3) fiscal capacity of the state. All states,
Washington, D.C., and U.S. territories have minimum allotments.
Page 29 GAO-22-104437 Behavioral Health and COVID-19
Table 2: Behavioral Health Block Grant Supplemental Funding from COVID-19 Relief Acts as of November 2021
Substance Abuse Prevention and Treatment Block
Community Mental Health Services Block Grant Grant
Purpose To allow states, U.S. territories, and other jurisdictions To allow states, U.S. territories, and other jurisdictions to
to provide comprehensive community mental health plan, implement, and evaluate activities to prevent and
services, and address needs and gaps in existing treat substance use disorder. This funding also is intended
treatment services for those with severe mental health to allow recipients to maximize efficiency in the existing
conditions. treatment and recovery infrastructure, promote support for
providers, and address unique local needs to deliver
substance use disorder prevention.
Amount Total amount awarded: $2.25 billion Total amount awarded: $3.075 billion
Consolidated Appropriations Act, 2021 (CAA) CAA appropriated $1.65 billion in December 2020;
appropriated $825 million in December 2020 for SAMHSA awarded $1.65 billion in March 2021.
states, territories, and other jurisdictions; the ARPA appropriated $1.5 billion in March 2021; SAMHSA
Substance Abuse and Mental Health Services awarded $1.425 billion in May 2021.
Administration (SAMHSA) awarded $825 million in
March 2021.a Award amounts ranged from $256,239 to Palau to about
$444 million to California. Per capita, amounts ranged from
American Rescue Plan Act of 2021 (ARPA) about $7 per capita in Nebraska to $18 per capita in
appropriated $1.5 billion in March 2021; SAMHSA Vermont.
awarded $1.425 billion in May 2021
Award amounts ranged from a total of $187,492 to
Palau to about $295 million to California. Per capita,
amounts ranged from about $5 per capita in Wyoming
to $9.55 per capita in American Samoa.
Grantees 50 states, Washington, D.C., American Samoa, 50 states, Washington, D.C., American Samoa, Guam,
Guam, Northern Mariana Islands, Puerto Rico, the Northern Mariana Islands, Puerto Rico, the U.S. Virgin
U.S. Virgin Islands, Federated States of Micronesia, Islands, Federated States of Micronesia, Palau, Republic
Palau, and Republic of Marshall Islands. of Marshall Islands, and the Red Lake Band of Chippewa
Indians.
Time frames Grantees have until March 14, 2023, to expend block grant funds from the CAA, and until September 30, 2025, to
expend block grant funds from ARPA.
Source: GAO analysis of COVID-19 relief acts and Substance Abuse and Mental Health Services Administration documentation. | GAO-22-104437
a
Appropriations from the CAA for the Community Mental Health Services Block Grant totaled $1.65
billion, however, the CAA specified that, of this amount, SAMHSA was to provide no less than 50
percent directly to community mental health centers. Therefore, SAMHSA awarded $825 million
through the Community Mental Health Services Block Grant and $825 million through the Community
Mental Health Centers Grant Program.
Page 30 GAO-22-104437 Behavioral Health and COVID-19
CCBHC Expansion Grants program. The COVID-19 relief acts
appropriated about $1.27 billion to the existing CCBHC Expansion Grants
program to expand the program’s reach. 42 CCBHCs are to provide a
comprehensive collection of services intended to create access, stabilize
people in crisis, and provide treatment and recovery support services for
those with the most serious and complex mental and substance use
disorders. As of November 2021, SAMHSA had awarded about $927
million of the total appropriated to 267 CCBHCs in 41 states and Guam. 43
(See fig. 9.) Grants were concentrated among several states; for
example, over 38 percent of the total number of CCBHC Expansion
Grants went to CCBHCs in five states. 44 Clinics in New York—one of the
five states—received almost 11 percent of the total grants, the largest
percentage of any state.
42The CCBHC Expansion Grants program funds must be used to provide access to
services including 24/7 crisis intervention services for individuals with serious mental
illness or substance use disorders, including opioid use disorders; children and
adolescents with serious emotional disturbance; and individuals with co-occurring mental
and substance disorders. SAMHSA expects that this program will provide comprehensive
24/7 access to community-based mental and substance use disorder services; treatment
of co-occurring disorders; and physical health care in one single location. CCBHCs cannot
be private, for profit organizations, and cannot refuse service to any individual on the basis
of ability to pay or place of residence.
Applicants were required to be community-based behavioral health clinics that either
currently met the certification criteria, or could be certified within four months. Extensive
CCBHC certification criteria fall into six areas: (1) staffing; (2) availability and accessibility
of services; (3) care coordination; (4) scope of services; (5) quality and other reporting;
and (6) organizational authority, governance, and accreditation.
The CCBHC Expansion Grants program received regular appropriations in addition to
appropriations from the COVID-19 relief acts.
43The CARES Act and CAA appropriated $250 million and $600 million, respectively, all of
which was awarded in fiscal years 2020 and 2021. ARPA appropriated $420 million, of
which about $77 million had been awarded as of November 2021.
A CCBHC Expansion Grants program grantee in Washington, D.C., was not able to use
the grant funds it was initially awarded, and according to SAMHSA officials, voluntarily
relinquished its award of about $4 million in April 2021. This award amount is therefore not
included in the total.
44These states are five of the 25 that participated in SAMHSA’s 2016 Planning Grant
program, which among other things, supported states’ ability to certify clinics as CCBHCs.
While CCBHC Expansion Grants from COVID-19 relief acts were available to entities that
met the CCBHC certification criteria and could be certified within 4 months of award,
SAMHSA gave priority to clinics in the 25 states that were awarded a planning grant.
Page 31 GAO-22-104437 Behavioral Health and COVID-19
Figure 9: Location of the Certified Community Behavioral Health Clinic Expansion Grants Program Grantees Awarded
Funding Provided by the COVID-19 Relief Acts as of November 2021
Page 32 GAO-22-104437 Behavioral Health and COVID-19
Notes: Clinics in Hawaii and the other U.S. territories besides Guam did not receive grants from the
Certified Community Behavioral Health Clinic (CCBHC) Expansion Grants program, and are therefore
not pictured above. The CCBHC Expansion Grants program is an existing grant program that has
received regular appropriations in addition to appropriations from the three COVID-19 relief acts. The
clinics above are only those that received funding from the COVID-19 relief acts.
Award amounts for funds provided by the CARES Act and CAA were up
to $4 million per CCBHC, with a project period of 2 years, while award
amounts for funds provided from ARPA were up to $2 million per CCBHC
per year for 2 years. 45
As of November 2021, most (about 74 percent) of the CCBHCs that
received grants from COVID-19 relief funds applied for funding prior to
the onset of the pandemic, according to SAMHSA officials. The officials
explained that rather than issue a new, COVID-19 specific fiscal year
2020 funding announcement, SAMHSA awarded the supplemental
funding provided through the CARES Act and CAA to CCBHCs that had
already applied for a grant, but had lower priority scores and had not
received funding from regular appropriations under an existing, fiscal year
2020 funding announcement. 46 Subsequently, SAMHSA issued an
additional fiscal year 2021 CCBHC Expansion Grants program funding
announcement, through which some clinics have been awarded grants
using remaining CAA funds and a portion of ARPA funds. According to
SAMHSA officials, the agency plans to issue another funding
announcement in fiscal year 2022 through which the remaining expansion
grant program funding provided under ARPA will be awarded to additional
clinics.
CCP. As of November 2021, FEMA awarded approximately $467 million
to 46 states, Washington, D.C., and four U.S. territories. 47 Award amounts
varied widely, and ranged from a total of $333,770 to New Hampshire to
45SAMHSA officials told us that unlike the CCBHC Expansion Grants program funds
provided under the CARES Act and CAA, which were available only through fiscal year
2021, the funds provided under ARPA do not expire and, therefore, awards can be made
across more than one fiscal year. As of November 2021, SAMHSA had obligated $77
million from ARPA for the second year of the project period.
46SAMHSA uses peer reviewers who are subject matter experts and generally not
SAMHSA employees to evaluate discretionary grant applications. Peer reviewers score
applications on a scale of 0-100. The priority score for each application is the mean of the
committee members’ total scores.
47The four U.S. territories receiving funding are Guam, the Northern Mariana Islands,
Puerto Rico, and the U.S. Virgin Islands.
Page 33 GAO-22-104437 Behavioral Health and COVID-19
about $110 million to California. 48 Alaska, Kentucky, and Mississippi,
Wyoming either withdrew their application or did not apply for funding.
(See app. V.) Recipients can use the funds to assist individuals and
communities in recovering from the effects of natural and human-caused
disasters through the provision of community-based outreach and
psychoeducational services. Historically, the CCP has been a program
through which states, Washington, D.C., U.S. territories, and tribes
affected by a major disaster can apply for and may receive funding. Such
funding typically has been used for disasters that covered a more limited
geographic area, such as natural disasters like hurricanes and wildfires.
However, in the case of COVID-19, CCP awards span the nation.
COVID-19 specific discretionary grant programs. The COVID-19 relief
acts appropriated almost $1.2 billion to be used for grants to address
emergency substance abuse or mental health needs in local communities
and grants for community mental health centers. In response, SAMHSA
created the Emergency Grants to Address Mental Health and Substance
Use Disorders During COVID-19 program and the Community Mental
Health Centers Grant Program. As of November 2021, SAMHSA had
awarded approximately $349 million in funding through the Emergency
Grants to Address Mental Health and Substance Use Disorders During
COVID-19 to 126 grantees, including state agencies, U.S. territories, and
tribal entities; and $825 million in Community Mental Health Centers grant
funding to 231 non-profit Community Mental Health Centers. (See table
3.)
48According to FEMA officials, recipients requested a specific amount of funding to
address their disaster specific needs and provided a written narrative and a budget to
justify that amount. The amount of funding FEMA awarded to recipients was based on
several factors including: (1) the amount of funding requested; (2) the justification
provided; (3) the demonstrated need for the services; and (4) the recipient’s capability to
provide services.
Page 34 GAO-22-104437 Behavioral Health and COVID-19
Table 3: COVID-19 Specific Discretionary Grant Programs from COVID-19 Relief Funding as of November 2021
Emergency Grants to Address Mental Health and
Substance Use Disorder During COVID-19 Community Mental Health Centers Grant Program
Purpose To provide crisis intervention services, mental and To enable community mental health centers to support
substance use disorder treatment, and other related and restore the delivery of clinical services that were
recovery supports for children and adults affected by the impacted by the COVID-19 pandemic and address the
COVID-19 pandemic. needs of individuals with serious emotional disturbance
(SED), serious mental illness (SMI), and individuals with
SMI or SED and substance use disorders, referred to as
co-occurring disorder.
Amount Total amount awarded: $349 million Total amount awarded: $825 million
CARES Act: appropriated $100 million in March 2020; CAA: appropriated $825 million in December 2020;c
the Substance Abuse and Mental Health Services SAMHSA awarded $825 million in September 2021.
Administration (SAMHSA) awarded about $110 million in Award amounts ranged from $221,747 to $5 million
April 2020.a depending on the minimum number of unduplicated
Consolidated Appropriations Act, 2021 (CAA): individuals with SMI, SED, and co-occurring disorder the
appropriated $240 million in December 2020; SAMHSA community mental health center planned to serve per
awarded about $239 million in March 2021. year with grant funds.
Base awards: State agencies and Washington, D.C.,
received funding amounts of up to $2 million, and
territories and tribal entities received up to $500,000.b
Supplements: According to SAMHSA officials, tribal
entities received supplements of about 217 percent of
their base award, while states received 143 percent of
their base awards. State agencies generally received
about $2.86 million.
Grantees 126 total including 50 state agencies, Washington, D.C., 231 non-profit community mental health centers including
four U.S. territories, and 71 tribal entities. state and local government-operated centers.
According to SAMHSA, all applicants that applied Grantees had to meet two additional requirements
received base funding in fiscal year 2020 or 2021 unless related to the provision of services: a community mental
they declined it or did not respond to inquiries from health center must be the applicant organization, and
SAMHSA. All grantees that received base funding must have at least 2 years of experience providing
received supplemental funding in fiscal year 2021 unless relevant services.
they declined it.
Time frames Project period of up to 16 months. Project period of up to 2 years.
Source: GAO analysis of COVID-19 relief acts and SAMHSA documentation. | GAO-22-104437
a
Ten million dollars of the $425 million in funding appropriated to SAMHSA in the CARES Act was not
designated for a specific program or activity. According to SAMHSA officials, the agency used this
$10 million to award additional grants through the Emergency Grants to Address Mental Health and
Substance Use Disorder During COVID-19 program.
b
Ninety-six grantees were selected for base funding from the fiscal year 2020 funding opportunity
announcement funding, which resulted in 32 unfunded applicants. SAMHSA officials said they
awarded grants starting at the highest score until the money was expended. In fiscal year 2021, 30
previously unfunded applicants were awarded base funding. Two tribal entities were not awarded
base funding, because, according to SAMHSA officials, one applicant never responded to an inquiry
after SAMHSA reached out multiple times, and one declined the funding.
c
These funds were part of $1.65 billion in total appropriations from the CAA to the Community Mental
Health Services Block Grant. The CAA specified that, of this amount, SAMHSA was to provide no
less than 50 percent directly to community mental health centers. Therefore, SAMHSA awarded $825
Page 35 GAO-22-104437 Behavioral Health and COVID-19
million through the Community Mental Health Services Block Grant and $825 million through the
Community Mental Health Centers Grant Program.
Remaining COVID-19 Our review of COVID-19 relief laws, award documentation, and data
Relief Funding for shows that the remaining approximately $635 million of the nearly $8.56
billion in total appropriated funding for HHS agencies from the three
Behavioral Health
COVID-19 relief acts is being provided through multiple HHS programs,
Provided Through Multiple including four suicide prevention grant programs.
HHS Programs, Including
Four Suicide Prevention Suicide prevention programs. As of November 2021, SAMHSA had
Grant Programs awarded almost $100.5 million of $120 million appropriated in the three
relief acts for suicide prevention through four grant programs. One of
these programs—the COVID-19 Emergency Response for Suicide
Prevention Grant Program—was created to respond to the pandemic.
The other three programs—the Suicide Prevention Lifeline Crisis Center
Follow-Up Expansion Grant Program, the National Suicide Lifeline and
Disaster Distress Helpline Cooperative Agreement, and the Garrett Lee
Smith Campus Suicide Prevention Grant Program—were previously
funded with annual appropriations; SAMHSA used relief funds to expand
the reach of these programs. (See table 4.)
Page 36 GAO-22-104437 Behavioral Health and COVID-19
Table 4: COVID-19 Relief Funding for Suicide Prevention Programs as of November 2021
COVID-19 relief Information about award amounts and types
grant program Purpose of grantees
Funded through the CARES Act
Suicide Prevention To provide an integrated hub that (1) ensures systematic Substance Abuse and Mental Health Services
Lifeline Crisis Center follow-up of suicidal persons who contact a National Suicide Administration (SAMHSA) awarded about $3
Follow-Up Expansion Lifeline Crisis Center; (2) provides enhanced coordination of million to three National Suicide Prevention
Grant Program crisis stabilization, crisis respite, and hospital emergency Lifeline crisis centers.a
department services; and (3) enhances coordination with Grantees applied for this grant program before
mobile on-site crisis response. the onset of the pandemic. SAMHSA awarded
these funds in fiscal year 2020 to the three
highest scoring non-funded applications from a
fiscal year 2019 funding opportunity
announcement.
Funded through the CARES Act and Consolidated Appropriations Act, 2021 (CAA)
COVID-19 To support states and communities during the COVID-19 SAMHSA awarded about $40 million from the
Emergency pandemic in advancing efforts to prevent suicide and suicide CARES Act to 50 grantees in fiscal year 2020,
Response for Suicide attempts among adults age 25 and older in order to reduce and $17.8 million from the CAA to 26 grantees
Prevention Grant the overall suicide rate and number of suicides in the U.S. in fiscal year 2021.b
Program SAMHSA required that a minimum of 25 percent of direct Grantees received requested funding amounts
services funding be used to support victims of domestic up to $800,000 for a 16 month project period.
violence. According to the funding opportunity Grantees included states, Washington, D.C.,
announcement, domestic violence can lead to situations of and U.S. territories; community-based
increased stress, anxiety, depression, and trauma, which are behavioral healthcare organizations; public
risk factors for suicide if left unaddressed. Current conditions health agencies; and federally recognized
exacerbate this situation for domestic violence victims. American Indian/Alaskan Native tribes, among
others.
Cooperative To manage, enhance, and strengthen the National Suicide SAMHSA awarded over $7 million in CARES
Agreement for Lifeline that routes individuals in the U.S. to a network of Act funding in fiscal year 2020, and $32 million
National Suicide certified crisis centers that links to local emergency, mental in CAA funding in fiscal year 2021 to Vibrant
Prevention Lifeline health, and social services resources; and support the Emotional Health.e
and Disaster Distress Disaster Distress Helpline to assist residents in the U.S. and According to SAMHSA officials, the over $7
Helpline its territories who are experiencing emotional distress million from the CARES Act was used to ensure
resulting from disasters and traumatic events.c that Vibrant Emotional Health was prepared for
This grant funding will be used to support the nation’s call potential increases in calls, online chats, and
centers’ capacity and technological readiness as the National text message support to the lifelines.
Suicide Lifeline’s shift to 988 becomes operational.d
Funded through the American Rescue Plan Act of 2021
Garrett Lee Smith To develop a comprehensive, collaborative, well-coordinated, SAMHSA awarded $741,252 to eight colleges
Campus Suicide and evidence-based approach to (1) enhance mental health and universities in fiscal year 2021.f Grantees
Prevention services for all college students; (2) prevent mental and received up to $102,000, and will each year for
substance use disorders; (3) promote help-seeking behavior 3 years. SAMHSA will continue to fund these
and reduce negative public attitudes; and (4) improve the grants annually during a 3-year project period
identification and treatment of at-risk college students so they for a total of $2.2 million.
can successfully complete their studies. Grantees included private and public non-profit
institutions of higher education, including tribal
colleges and universities.
Source: GAO analysis of SAMHSA award documentation. | GAO-22-104437
Page 37 GAO-22-104437 Behavioral Health and COVID-19
a
The National Suicide Prevention Lifeline is a 24/7 confidential suicide prevention hotline and chat
network for anyone in the United States experiencing a suicidal crisis or emotional distress. Callers
can dial a single toll-free number to be routed to the closest certified crisis center within the National
Suicide Prevention Lifeline network. The network includes over 170 local- and state-funded crisis
centers located across the United States.
b
According to SAMHSA officials, the agency was not able to fund all the applicants that applied to the
funding opportunity announcement in fiscal year 2020. Later, using CAA funds, SAMHSA awarded
funding to 26 previously unfunded applicants from the 2020 funding opportunity announcement.
c
The Disaster Distress Helpline is a confidential 24/7 crisis support service that connects anyone in
the United States experiencing distress as a result of a disaster and/or traumatic event with a crisis
center responder through a sub-network of the National Suicide Lifeline crisis centers.
d
In 2020, the Federal Communications Commission and The National Suicide Hotline Designation Act
of 2020 designated 988 as the new three-digit number for the National Suicide Prevention Lifeline.
e
Vibrant Emotional Health will be the administrator of the 988 dialing code for the National Suicide
Prevention Lifeline.
In addition, 25 colleges received the Garrett Lee Smith Campus Suicide Prevention awards through
f
SAMHSA’s annual appropriation totaling $2.5 million.
Other programs. Behavioral health-related funding provided under the
COVID-19 relief acts also was used to support several additional
programs. For example, the CARES Act appropriated $15 million to
support tribal entities, and according to SAMHSA, the agency chose to
award these funds as supplements to the existing Tribal Behavioral
Health Grant Program based on tribal consultation. 49 As of November
2021, SAMHSA had awarded the $15 million to 154 current Tribal
Behavioral Health grantees for a total of $97,402 each. Additionally, the
CAA and ARPA appropriated a total of $100 million to expand the reach
of the Project AWARE (Advancing Wellness and Resilience in Education)
State Education Agency Grants program, and the National Child
Traumatic Stress Network. As of November 2021, SAMHSA had awarded
49Specifically, the CARES Act required that not less than $15 million of SAMHSA’s
appropriations be allocated to tribes, tribal organizations, urban Indian health
organizations, or health or behavioral health service providers to tribes.
Page 38 GAO-22-104437 Behavioral Health and COVID-19
about $61 million of this funding to, for example, state education agencies
and tribal entities. 50
Additionally, ARPA appropriated $100 million to the Health Resources
and Services Administration for the Behavioral Health Workforce
Education and Training Program for Professionals; the agency had
awarded about $22 million of this funding to 56 grantees as of November
2021. 51 ARPA also appropriated $20 million to CDC to use for an
education and awareness campaign encouraging healthy work
conditions, and use of mental health and substance use disorder services
by health care professionals. According to CDC, as of November 2021,
the agency had obligated $4 million of this funding.
HHS agencies, including SAMHSA, the Health Resources and Services
Administration, and CDC, had yet to obligate the remaining $296 million
of ARPA funds as of November 2021. These include funds to be used to
provide support for pediatric mental health care access, local behavioral
health needs and substance use disorder services, and mental health and
substance use disorder awareness and training for health care
professionals.
50The CAA and ARPA appropriated a total of $80 million to Project AWARE, and as of
November 2021, SAMHSA had awarded about $50 million of this funding to 10 grantees.
Funding is intended to build or expand the capacity of state education agencies in
partnership with state mental health agencies and three local education agencies to
increase awareness of mental health issues among school-aged youth, provide training
for those who interact with school-aged youth to detect and respond to mental health
issues, and connect school-aged youth who may have behavioral health issues, and their
families, to needed services.
The CAA and ARPA appropriated a total of $20 million to the National Child Traumatic
Stress Network, and as of November 2021, SAMHSA had awarded almost $11 million of
this funding to nine grantees. Grants were awarded through two related programs under
this initiative with the purposes of (1) providing national expertise on specific types of
traumatic events, population groups, and service systems; and (2) providing and
increasing access to effective trauma-focused treatment and services systems in
communities for children and adolescents, and their families.
51Grantees included accredited doctoral, internship, and post-doctoral residency programs
of health service psychology (including clinical psychology, counseling, and school
psychology), among others. Recipients of the Behavioral Health Workforce Education and
Training Program for Professionals are to train graduate level students of social work,
psychology, and other behavioral and mental health disciplines to work with vulnerable
populations, particularly children, adolescents and transitional-aged youth at risk for
behavioral health disorders. According to the Health Resources and Services
Administration, this is a multi-year award; the remaining $80 million will be awarded in
future fiscal years in installments for a 5-year period.
Page 39 GAO-22-104437 Behavioral Health and COVID-19
COVID-19 Relief
Funds for Behavioral
Health Could
Generally Serve
Populations at Higher
Risk; Selected
Funding Recipients’
Plans for Serving
These Populations
Varied
COVID-19 Relief Funds Our review of program documentation shows that the majority of COVID-
for Behavioral Health 19 relief funds for behavioral health, as represented by the six largest
behavioral health programs noted previously and listed in table 5, could
Generally Allow Funding
generally serve all six populations stakeholders most frequently identified
Recipients to Serve as being at higher risk of behavioral health effects related to the
Populations that May be At pandemic, as we describe in this report. 52 Each of the six of the largest
Higher Risk behavioral health programs have specific requirements or
recommendations regarding any target populations for each program.
Some of the six higher-risk populations are specifically identified in these
requirements, as shown in table 5.
52For the remaining COVID-19 behavioral health relief programs and activities—with
appropriated funding totaling about $635 million—the primary populations of focus varied,
but a number of the identified higher-risk populations are specifically targeted. For
example, about $215 million of this funding is for programs focusing on children,
adolescents, and young adults, including American Indian and Alaska Native youth.
Another $140 million is for programs focusing on health care workers, while $180 million is
for programs with a more general population focus like the National Suicide Prevention
Lifeline.
Page 40 GAO-22-104437 Behavioral Health and COVID-19
Table 5: Target Population Requirements for Each of the Six Largest Behavioral Health Programs that Provided COVID-19
Relief Funding
Program Requirements
Community Mental Health The target populations for the MHBG are adults with serious mental illness (SMI) and children with
Services Block Grant serious emotional disturbance (SED).
(MHBG)a Each grantee must expend at least 10 percent of its block grant funds each fiscal year (or at least 20
percent by the end of the succeeding fiscal year) to support evidence-based programs to address
early serious mental illness.
Further, the MHBG has a set-aside requirement for children with SED—each year the state shall
expend not less than the amount expended in fiscal year 1994.
MHBG funds cannot be used for primary prevention activities. Grantees cannot use MHBG funds for
those who are not diagnosed with a SMI.
Substance Abuse The SABG population focus is at-risk individuals or persons in need of substance use disorder (SUD)
Prevention and Treatment treatment. The SABG program targets five priority populations and service areas: (1) pregnant
Block Grant (SABG)a women and women with dependent children; (2) persons who inject drugs; (3) tuberculosis services;
(4) early intervention services for HIV/AIDS; and (5) primary prevention services.
Grantees must spend no less than 20 percent of their allotment on substance abuse primary
prevention strategies directed at individuals not identified to be in need of treatment.
Emergency Grants to The target populations for the emergency COVID-19 grants were individuals with SMI, SUD, and co-
Address Mental and occurring SMI and SUD, although language in the grant announcement also notes that they are
Substance Use Disorders generally to serve children and adults impacted by the COVID-19 pandemic, including those with
During COVID-19 mental disorders less severe than SMI.
Specifically, at least 80 percent of the grant funds must be used for direct services. Of that amount
• 70 percent must go to the target populations,
• 10 percent must go to health care practitioners with mental disorders (less severe than SMI), and
• 20 percent can be used for all other individuals with mental disorders less severe than SMI.
Community Mental Health The populations of focus for the Community Mental Health Centers Grant Program include individuals
Centers Grant Program with SMI, SED, and individuals with co-occurring SUDs. Further, developing and providing resources
to address the mental health needs of community mental health center staff is a required grant
activity.
The funding announcement also lists among its allowable activities those activities serving the
following populations: school age youth at risk for SED; children and youth at risk for maltreatment;
vulnerable populations, such as minority populations and individuals residing in economically
disadvantaged communities; and incarcerated persons.
Certified Community The CCBHC Expansion Grants program participating clinics must provide services to any individual
Behavioral Health Clinics (regardless of their ability to pay or place of residence), and do not have specific population
(CCBHC) Expansion requirements. Nonetheless, according to program documentation, CCBHCs are expected to serve
Grants individuals with SMI, those with severe SUD, children and adolescents with SED, and those with co-
occurring mental, substance use, or physical health disorders.
The Federal Emergency FEMA’s Crisis Counseling Assistance and Training Program is intended to provide services to any
Management Agency affected disaster survivor who may need assistance in coping with the effects of the disaster, such as
(FEMA) Crisis Counseling those who were in the impacted area at the time of the incident or live in the impacted area. Its
Assistance and Training funding recipients conduct a needs assessment that identifies the most vulnerable populations that
Program would benefit from receiving crisis counseling services. FEMA notes that in most disaster situations,
children, adolescents, older adults, underserved populations, individuals with disabilities, and
individuals with access or functional needs may benefit from program services, but the needs
assessment may reveal additional groups who are vulnerable to disaster effects or who have been
particularly affected by the disaster.
Page 41 GAO-22-104437 Behavioral Health and COVID-19
Source: GAO analysis of Substance Abuse and Mental Health Services Administration and FEMA documents. | GAO-22-104437
a
Fiscal year 2020-2021 block grant guidance also notes that in addition to the required target
populations for each block grant, grantees are encouraged to consider the following populations:
persons experiencing homelessness; individuals involved in the criminal or juvenile justice systems;
persons living in rural areas; underserved racial and ethnic populations; individuals who are lesbian,
gay, bisexual, transgender, or queer/questioning; and persons with disabilities.
In addition to the requirements described in table 5, our review of
program documentation for the six largest behavioral health programs
determined the following additional information specific to the ways these
programs can serve the higher-risk populations identified by stakeholders:
People from certain racial and ethnic groups. People from various
racial and ethnic groups can be served by all six of the largest behavioral
health programs, and funding recipients are specifically prohibited from
discriminating on the basis of race, color, nationality, or English
proficiency, among other factors. Additionally, most of the programs
specifically recommend that people from certain racial and ethnic groups
be target populations. For example, block grant guidance for fiscal years
2020-2021 notes that in addition to required target populations, states are
encouraged to consider targeting, among others, underserved racial and
ethnic groups. SAMHSA also requires that recipients of the CCBHC
Expansion Grants and Community Mental Health Centers grants submit
disparity impact statements, which include identifying racial, ethnic,
sexual, and gender groups vulnerable to behavioral health disparities,
and plans for addressing identified differences in access to and use of
services. CCP recipients are directed to adapt the program to the needs
of local populations, including racial, ethnic, and cultural groups.
However, none of the six programs have specific funding set-asides for
certain racial and ethnic groups, although funding recipients that are
tribes or tribal organizations would generally serve American
Indians/Alaska Natives.
Health care workers. As noted in table 5, two of the six largest
behavioral health programs—the emergency COVID-19 grants, and
Community Mental Health Centers Grant Program—require that services
be provided to health care workers. Health care workers could also
receive services through the other four programs if they meet those
programs’ requirements.
However, some barriers could exist in serving certain health care workers
who do not meet any existing requirements related to income limits or
insurance. For example, officials from one state said that they had to lift a
state financial screening requirement for health care workers to be able to
Page 42 GAO-22-104437 Behavioral Health and COVID-19
provide more services to this population with the emergency COVID-19
grant. They said many health care workers were not otherwise eligible for
services, because their incomes were more than 200 percent above the
poverty level—a state financial screening requirement.
Children and adolescents. All six of the largest behavioral health
programs may serve children and adolescents that meet the programs’
other requirements, but only the Community Mental Health Services
Block Grant has a related set-aside requirement (for children with serious
emotional disturbance). Additionally, in documentation for the six
programs, SAMHSA and FEMA note that these funds could be used for
programs or services related to children. For example, in its May 2021
letter to states regarding ARPA funds, SAMHSA recommended using
Community Mental Health Services Block Grant funds for services for
children, such as screening and assessment within a crisis continuum,
mobile crisis response and stabilization, residential crisis services, and
ongoing care coordination.
People with pre-existing behavioral health conditions. As shown in
table 5, people with certain pre-existing behavioral health conditions can
be served by all six of the largest behavioral health programs, although all
of these programs—other than the CCP—generally focus on those with
more severe conditions, such as serious mental illness. For example, the
target populations for the Community Mental Health Services Block Grant
are adults with serious mental illness and children with serious emotional
disturbance, as opposed to those with less severe, but pre-existing,
behavioral health conditions. 53 FEMA’s CCP does not specifically target
services to individuals with pre-existing behavioral health conditions, but
rather provides services to anyone, regardless of previous diagnosis or
current symptoms, who may be experiencing disaster-related negative
effects. 54
53SAMHSA defines serious mental illness as someone over the age of 18 having (within
the past year) a diagnosable mental, behavior, or emotional disorder that causes serious
functional impairment that substantially interferes with or limits one or more major life
activities. For people under the age of 18, the term “serious emotional disturbance” refers
to a diagnosable mental, behavioral, or emotional disorder in the past year, which resulted
in functional impairment that substantially interferes with or limits the child’s role or
functioning in family, school, or community activities.
54FEMA officials said that the CCP provides coping mechanisms and psycho-educational
support in one-time sessions, and can also provide those dealing with more severe
behavioral health issues with referrals to existing resources better suited for long-term or
continued support.
Page 43 GAO-22-104437 Behavioral Health and COVID-19
Young adults. All six of the largest behavioral health programs generally
allow young adults to be served by these programs if they meet those
programs’ other requirements, although none of the programs specifically
set-aside funds for this population. SAMHSA has, however, specifically
recommended states consider using block grant funds for programs
related to young adults. For example, in its May 2021 letter to states
regarding ARPA funds, SAMHSA recommends using Substance Abuse
Prevention and Treatment Block Grant funds for strategies to improve
substance misuse outcomes, especially among young adults age 18-25
and those over 26 years of age.
People facing financial distress. All six of the largest behavioral health
programs generally allow people facing financial distress to be served by
these programs. Specifically, the five SAMHSA grant programs are
generally intended to serve people with low incomes or without public or
commercial insurance. For example, SAMHSA has indicated that the
block grants may be used to fund priority treatment and support services
for low-income individuals, and individuals without insurance or for whom
coverage is terminated for short periods of time. The sixth program—
FEMA’s CCP—can generally serve any individual impacted by a disaster,
such as the pandemic, but the program guidance specifically notes that
people who have lost homes or jobs as a result of a disaster, among
others, may benefit from crisis counseling services.
SAMHSA officials said that it will be some time before the agency is able
to determine who was served by the COVID-19 relief-funded grants.
When asked about potential analysis plans for data reported by grantees
about populations served by the COVID-19 relief act-funded programs,
SAMHSA officials said they are starting to look at data—examining
demographics such as race, ethnicity, and gender of clients served
through these programs. 55 SAMHSA officials told us that it was too early
in the process to have a more specific data analysis plan, noting that
officials wanted to review some of the data as it comes in to determine
what additional analysis might be needed. Nonetheless, the SAMHSA
officials said that it is important to examine populations served by
programs receiving COVID-19 relief funds to determine whether target
populations were reached, and whether there were any gaps in intended
55Recipients of COVID-19 relief act SAMHSA grants are required to report a variety of
information about the clients served by the grants, including their demographic
characteristics, diagnoses, and treatment services provided.
Page 44 GAO-22-104437 Behavioral Health and COVID-19
populations served—and said that the agency planned to do so in the
future.
Selected Funding Selected funding recipients we spoke with in Colorado, Mississippi, New
Recipients Reported York, Washington, D.C., and West Virginia reported varying ways they
were using, or planned to use, awards from COVID-19 relief funds for
Various Ways They
behavioral health to reach the six populations stakeholders identified as
Intended to Use Relief at higher risk for behavioral health effects. 56 See figure 10 for examples of
Funds to Reach Higher- funding recipient efforts targeting these six populations.
Risk Populations, but
Noted Some Challenges in
Using the Funds to Do So
56Our interviews with funding recipients in our four selected states and Washington, D.C.,
were conducted from March through June 2021. At the time of our interviews, we were
generally only able to speak with funding recipients about awards received from CARES
Act and CAA funds, as ARPA funds had not yet been awarded.
Page 45 GAO-22-104437 Behavioral Health and COVID-19
Figure 10: Examples of How Selected Funding Recipients Have Used or Planned to Use COVID-19 Relief Funds for Behavioral
Health to Reach Higher-Risk Populations
Notes: We interviewed 18 funding recipients from four selected states and Washington, D.C.
Specifically, we interviewed at least one recipient of each of the different types of Substance Abuse
and Mental Health Services Administration grants that had been distributed as of March 2021, as well
as recipients of Federal Emergency Management Agency Crisis Counseling Assistance and Training
program funds.
Additionally, some funding recipients described programs that targeted
multiple populations that stakeholders identified as being at higher risk.
For example, using funds from FEMA’s CCP, officials in one state
analyzed public health data to locate the counties with the highest
COVID-19 infection and mortality rates, and higher unemployment rates.
Page 46 GAO-22-104437 Behavioral Health and COVID-19
They then focused their crisis counseling program on the 12 most
affected counties. The officials noted that often people from certain racial
and ethnic groups and people with poor financial status—either due to a
previous history of poverty or to the pandemic—were those being served
by this program. Officials told us in May 2021 that of all crisis contacts,
communities served were 50 percent Black, 17 percent Hispanic or
Latino, 25 percent White, and 3 percent Asian. Officials also noted that
they are conducting outreach to children and school populations as part
of their crisis counseling program.
Some of the selected funding recipients also described various program
requirements and other features that they said can limit their ability to
serve some of the higher-risk populations, such as people with less
severe pre-existing behavioral health conditions and young adults. The
challenges the funding recipients cited are, in general, long-standing
grant rules or reporting requirements that pre-date the COVID-19
pandemic, and some are designed, in part, to help SAMHSA monitor
progress toward program goals and help ensure accountability for the use
of the federal funding. However, some of the funding recipients indicated
these requirements posed a particular challenge in the context of the
pandemic. SAMHSA officials described steps they have taken to help
address some of the challenges cited by funding recipients, but also
indicated that some grant requirements were beyond their authority to
waive.
Grant requirements regarding populations served. Some block grant
recipients and recipients of two types of COVID-19 specific emergency
grants reported challenges related to grant target populations that could
limit their ability to serve certain higher-risk populations. 57 For example,
officials from one state said use of the funds from the Emergency Grants
to Address Mental Health and Substance Use Disorders During COVID-
19 program has been challenging given the requirement for 70 percent of
funds to be used for populations meeting specific criteria for substance
use disorder and serious mental illness. The officials added that during
the pandemic there has been an increase in the volume of people
needing crisis services, such as teachers, but not all of these people meet
the criteria for substance use disorder and serious mental illness.
Additionally, officials from a behavioral health clinic noted frustration
related to the COVID-19 Emergency Response for Suicide Prevention
57The two types of COVID-19 specific emergency grants we refer to in this section are the
Emergency Grants to Address Mental Health and Substance Use Disorders During
COVID-19 and the COVID-19 Emergency Response for Suicide Prevention Grant.
Page 47 GAO-22-104437 Behavioral Health and COVID-19
Grant, because they have to turn away young adults under age 25,
because the organization is restricted from using these grant funds for
individuals aged 18-24.
SAMHSA officials said the agency has determined that block grant
requirements for populations served are beyond SAMHSA’s authority to
waive. However, they stated that they are not worried that grant
requirements will limit any higher-risk populations from receiving services.
Agency officials noted, for example, that the emergency COVID-19 grants
allowed some funding to be used to serve persons with less severe
mental illness. SAMHSA officials added that they had not been made
aware of some grantees’ concern regarding serving persons with mental
disorders less severe than serious mental illness, but had heard concerns
about serving health care workers. 58
Client data reporting requirements. Some recipients of block grants,
two types of COVID-19 specific emergency grants, and the tribal
behavioral health grant reported challenges related to client data
reporting requirements, which could affect serving higher-risk populations.
Specifically, SAMHSA requires grantees use a Government Performance
and Results Act (GPRA) tool to collect and report data from clients at
intake, follow-up, and discharge. 59 Officials in one state, for example, said
that because of this GPRA tool, the state has declined to use Emergency
Grants to Address Mental Health and Substance Use Disorders During
COVID-19 funds for youth and adolescents accessing high intensity
programs during the pandemic, because the tool would be too
burdensome to complete for this population.
SAMHSA officials said that due to the pandemic, SAMHSA lessened a
few GPRA-related data reporting requirements for grantees. For example,
58SAMHSA officials said some emergency COVID-19 grantees reported difficulty
identifying health care workers in need of services due to the stigma against receiving
behavioral health services—noting that some health care workers may not want to receive
behavioral health treatment out of fear that doing so could affect their certification or
licensure.
59The GPRA tool is a questionnaire that, according to SAMHSA officials, the agency
developed to help HHS meet requirements of the Government Performance and Results
Act of 1993 and the GPRA Modernization Act of 2010. The questionnaire is administered
by providers at client intake, 6-month follow-up, and discharge from a SAMHSA funded
treatment program to collect data about each individual served. Information collected
about the individuals served includes their demographic characteristics, diagnoses, and
treatment services provided. SAMHSA officials said that all recipients of COVID-19 relief
act funds are required to use this data collection tool with most clients, except, for
example, clients who receive one time services.
Page 48 GAO-22-104437 Behavioral Health and COVID-19
instead of requiring data collection to be done face-to-face with clients,
SAMHSA allows information to be collected via telehealth, email, or
through paper reporting. Also, officials said that data collection is not
required for all clients, such as people receiving virtual education or
people receiving one-time services. SAMHSA officials said that these
flexibilities had been communicated during webinars or calls with
grantees.
Limitations in how the funds can be spent. Some recipients of block
grants, two types of COVID-19 specific emergency grants, the tribal
behavioral health grant, and CCP funds reported challenges related to
prohibitions on using funds for certain purposes, such as building
construction, or purchasing technology equipment. An official in one state
said that not being able to spend block grant funds on capital investment
is a challenge, noting that a lack of residential services due to facility
limitations are a barrier to care in the state, and that services can only be
provided if there are locations to provide them. Officials in another state
said the federal government should consider allowing for the purchase of
equipment and supplies for clients with relief grant funds. They said that
providers were using telehealth as a major tool for ensuring access and
continuity of care during the pandemic, and because clients have few
resources, it is challenging to ensure these clients have full access to
telehealth.
SAMHSA officials told us that they have allowed for some flexibilities with
block grant relief act funding; for example, allowing for the operation of
crisis lines, which agency officials indicated are not generally allowed
under regular grant rules. Officials said that they would consider requests
to waive block grant requirements other than flexibilities specifically
referenced in guidance letters to grantees on a case by case basis—to
the extent it is within their authority to do so. For example, the agency has
determined that block grant rules related to spending on capital
infrastructure are beyond SAMHSA’s authority to waive. Regarding
spending funds on equipment for clients, SAMHSA officials said the
agency allows grantees to use funding for technology for grantee staff,
but not their clients. Officials said this is related to audit requirements and
a need for the grantee to maintain custody and accountability of such
supplies purchased with federal dollars.
Program project periods. Some of the funding recipients that received
the two types of COVID-19 specific emergency grants, the CCBHC
Expansion Grants, and CCP funds reported challenges related to
Page 49 GAO-22-104437 Behavioral Health and COVID-19
program project period lengths. 60 For example, officials in one state said it
is hard to get a program initiated and operating—and to get any
meaningful outcomes—in such a short time period. They added that grant
timelines also affect staffing, as staff will begin looking for new jobs before
the grant ends if there is not a guarantee that the grant will be renewed.
SAMHSA officials said that grantees have some flexibilities related to the
grant project periods, such as requesting no-cost extensions to the
project time period, and that the agency attempts to be flexible to help
ensure grantees can spend their funds to provide services. FEMA officials
also provided us with documentation showing that they have allowed for
and said they will continue to allow for additional extensions to CCP
project time periods.
Workforce challenges. Funding recipients—particularly tribal grantees
and grantees in two states—reported workforce concerns that could affect
their ability to use COVID-19 relief funds for behavioral health. 61 For
example, one state CCBHC Expansion Grants recipient said that while
she did not see any limitations or challenges with the grant itself, she was
concerned that it could be a challenge to fill all of the positions for the
extra employees her clinic wants to hire. She said that due to low
reimbursement rates, the salaries her clinic can offer are not as
competitive as those other clinics can offer.
We provided a draft of this report to HHS and FEMA for review and
Agency Comments comment. HHS and the Department of Homeland Security provided
technical comments, which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Health and
Human Services, the Secretary of Homeland Security, the FEMA
Administrator, appropriate congressional committees, and other
interested parties. The report is also available at no charge on the GAO
website at http://www.gao.gov.
60The two types of COVID-19 specific emergency grants have a project period of up to 16
months, and CCBHC Expansion Grants have a project period of up to 2 years. The two
programs within the CCP (Immediate Services Program, and Regular Services Program)
have different project periods, and while extensions can be requested as long as needed,
justified, and in the best interest of the public, funds are generally intended to be used
within a little over a year of a major disaster declaration, according to FEMA officials.
61ARPA appropriated $100 million for behavioral health workforce education and training.
However, because this funding is generally for student recruitment or training, it may not
address the more short-term behavioral health workforce hiring challenges grantees
described, such as less competitive salary rates.
Page 50 GAO-22-104437 Behavioral Health and COVID-19
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or at HundrupA@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix VI.
Alyssa M. Hundrup
Director, Health Care
Page 51 GAO-22-104437 Behavioral Health and COVID-19
Congressional Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chair
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chair
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Republican Leader
Committee on Energy and Commerce
House of Representatives
Page 52 GAO-22-104437 Behavioral Health and COVID-19
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Richard Neal
Chairman
The Honorable Kevin Brady
Republican Leader
Committee on Ways and Means
House of Representatives
Page 53 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Appendix I: Objectives, Scope, and
Methodology
Methodology
The CARES Act includes a provision for GAO to report on its ongoing
monitoring and oversight efforts related to the COVID-19 pandemic. 1 In
this report, we describe
1. populations that may be at higher risk of behavioral health effects
related to the COVID-19 pandemic;
2. the amount and type of funding the federal government provided in
COVID-19 relief to states, providers, and other organizations to
address behavioral health needs; and
3. whether COVID-19 relief funds for behavioral health could serve
identified populations that may be at higher risk of behavioral health
effects related to the COVID-19 pandemic, and how selected funding
recipients plan on using relief funds to serve these populations.
To address all three objectives, we interviewed or obtained written
responses from a range of stakeholders, and interviewed recipients of
COVID-19 relief funds for behavioral health relief in four states and
Washington, D.C. We also analyzed additional information that pertained
to each of the objectives, such as selected behavioral health research,
documents from stakeholder organizations, federal agencies, and others;
and examined relevant laws.
Stakeholder Interviews We interviewed or obtained written responses from stakeholders that
represented a range of roles and perspectives with respect to behavioral
health during the COVID-19 pandemic. In particular, we obtained
information from relevant federal agencies; behavioral health provider
associations; other health care provider associations; consumer groups;
and national associations representing state behavioral health agencies
and American Indian/Alaska Native health organizations. (See table 6.) In
addition to these organizations, we spoke with four university-affiliated
researchers and one university-based research working group with
knowledge about topics such as behavioral health risk and protective
factors; behavioral health during the pandemic; and the impact of
disasters, recessions, and social isolation on behavioral health. We
selected national organizations we identified as representing behavioral
1Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020). We have regularly issued
government-wide reports on the federal response to COVID-19. For the latest report, see
GAO, COVID-19: Additional Actions Needed to Improve Accountability and Program
Effectiveness of Federal Response, GAO-22-105051 (Washington, D.C.: Oct. 27, 2021).
Our next government-wide report will be issued in January 2022 and will be available on
GAO’s website at https://www.gao.gov/coronavirus. We will continue to monitor behavioral
health funding as part of this ongoing COVID-19 related oversight.
Page 54 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
health care providers, other health care providers, and individuals with
behavioral health conditions. We also selected researchers we identified
as having relevant knowledge based on their published work. We
identified some organizations and researchers based on the
recommendations of other stakeholders. We also reviewed reports,
research, and other documentation provided by these stakeholders that
pertained to our objectives.
Table 6: Federal Agencies, Health Care Provider Associations, and Other
Organizations That Provided Information about Behavioral Health during the
COVID-19 Pandemic
Type of stakeholder Organization
Federal agencies • Administration for Children and Families
• Centers for Disease Control and Prevention
• Federal Emergency Management Agency
• Health Resources and Services Administration
• National Institutes of Health
• Substance Abuse and Mental Health Services
Administration
Behavioral health provider • American Association for Geriatric Psychiatry
associations • American Psychiatric Association
• American Psychiatric Nurses Association
• American Psychological Association
• American Society of Addiction Medicine
• NAADAC, the Association for Addiction Professionals
• National Association of Addiction Treatment Providers
• National Council for Mental Wellbeing
(formerly National Council for Behavioral Health)
Other health care provider • American Academy of Family Physicians
associations • American Association of Critical-Care Nurses
• American Medical Association
• America’s Essential Hospitals
• National Association of Community Health Centers
Consumer groups • Mental Health America
• National Alliance on Mental Illness
National associations • National Association of State Alcohol and Drug Abuse
representing state Directors
behavioral health agencies • National Association of State Mental Health Program
and American Directors
Indian/Alaska Native health
• National Indian Health Board
organizations
Source: GAO. | GAO-22-104437
Page 55 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
As part of our stakeholder interviews, in a sample of four states—
Colorado, Mississippi, New York, and West Virginia—and Washington,
D.C., we interviewed state agencies and other selected organizations
within those states that received federal COVID-19 relief funding for
behavioral health. These states and Washington, D.C., were selected
based on consideration of a number of different criteria including (1) the
extent to which they were ranked in the top 10 across seven behavioral
health metrics, including rates of self-reported serious mental illness,
rates of any substance use disorder, and rates of suicide deaths and drug
overdose deaths; (2) variation in the number and type of Substance
Abuse and Mental Health Services Administration (SAMHSA) CARES
Act-funded grants received; (3) variation in per capita funding ranking for
CARES Act-funded SAMHSA grants and Federal Emergency
Management Agency (FEMA) Crisis Counseling Assistance and Training
Program (CCP) funding; and (4) whether the state had expanded
Medicaid. 2 We also selected our sample based on overall variation in
geographic region, number of COVID-19 cases and deaths as of
February 2021, racial/ethnic group percentages, and percentage of the
population in poverty.
Specifically, we interviewed selected recipients of the different types of
SAMHSA grants specified in the CARES Act and Consolidated
Appropriations Act, 2021 that had been distributed as of March 2021, as
well as recipients of FEMA CCP funds. (See table 7 for more information
on funding recipients interviewed, including the types of funding
discussed.)
2Under the Patient Protection and Affordable Care Act, states have the option to expand
their Medicaid programs to cover nearly all adults with incomes at or below 133 percent of
the federal poverty level. States that choose to expand their programs receive a higher
federal matching rate for the Medicaid expansion enrollees.
Page 56 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
Table 7: Federal COVID-19 Behavioral Health Relief Funding Recipients Interviewed
State Agency or organization Type of organization COVID-19 relief funding discussed during interview
Colorado Office of Behavioral Health state agency Community Mental Health Block Grant (MHBG) and
Substance Abuse Prevention and Treatment Block
Grant (SABG); Emergency Grants to Address Mental
Health and Substance Use Disorders During COVID-19
Department of Public Health & state agency COVID-19 Emergency Response for Suicide Prevention
Environment Office of Suicide Grants
Prevention
Department of Public Health & state agency Crisis Counseling Assistance and Training Program
Environment Emergency
Preparedness
Aurora Mental Health Center Certified Community CCBHC Expansion Grants program
Behavioral Health Clinic
(CCBHC)
Ute Mountain Ute Tribe tribal organization Tribal Behavioral Health/Native Connections Grant
supplement and COVID-19 Emergency Response for
Suicide Prevention Grants
Rocky Mountain Crisis crisis center Suicide Prevention Lifeline Crisis Center Follow-Up
Partners Expansion Grant
Mississippi Department of Mental Health state agency MHBG and SABG; Emergency Grants to Address
Mental Health and Substance Use Disorders During
COVID-19
Southwest Mississippi Mental CCBHC CCBHC Expansion Grants program
Health Complex
New York Office of Mental Health state agency MHBG; Emergency Grants to Address Mental Health
and Substance Use Disorders During COVID-19; Crisis
Counseling Assistance and Training Program
Office of Addiction Services state agency SABG
and Supports
Samaritan Daytop Village CCBHC CCBHC Expansion Grants program
BestSelf Behavioral Health CCBHC COVID-19 Emergency Response for Suicide Prevention
Grants and CCBHC Expansion Grants program
Saint Regis Mohawk Tribe tribal organization Tribal Behavioral Health/Native Connections Grant
supplement
Washington, Department of Behavioral state agency MHBG and SABG; Emergency Grants to Address
D.C. Health Mental Health and Substance Use Disorders During
COVID-19; Crisis Counseling Assistance and Training
Program
Ivan Walks and Associates – behavioral/mental health CCBHC Expansion Grants program
Integrated Health Resourcesa clinic
National Council of Urban tribal organization Tribal Behavioral Health/Native Connections Grant
Indian Health supplement
Page 57 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
State Agency or organization Type of organization COVID-19 relief funding discussed during interview
West Virginia Department of Health and state agency MHBG and SABG; Emergency Grants to Address
Human Resources Mental Health and Substance Use Disorders During
COVID-19; Crisis Counseling Assistance and Training
Program
Prestera Center CCBHC CCBHC Expansion Grants program
Source: GAO. | GAO-22-104437.
Note: At the time of our interviews, we were generally only able to speak with funding recipients about
awards received from CARES Act and CAA funds, as ARPA funds had not yet been awarded.
a
Ivan Walks and Associates – Integrated Health Resources received a CCBHC expansion grant, but
was not able to use the grant funds. According to SAMHSA officials, this clinic voluntarily relinquished
its award in April 2021, which was shortly after we interviewed them.
Identifying Populations at To identify populations that may be at higher risk of behavioral health
Potentially Higher Risk of effects due to the COVID-19 pandemic, we analyzed selected research
and information from federal and state officials and other stakeholders.
Behavioral Health Effects
We considered behavioral health effects related to the pandemic to
Due to the Pandemic include new or exacerbated behavioral health symptoms and conditions,
such as those related to anxiety, depression, and substance use;
behavioral health effects also include suicidal ideation, suicide attempts,
and suicide deaths.
Selected research. We reviewed a range of reports, studies, resources,
and data published by federal agencies and other organizations. For
example, we reviewed Centers for Disease Control and Prevention (CDC)
Morbidity and Mortality Weekly Reports and other CDC publications about
topics such as self-reported behavioral health symptoms and substance
use, and emergency department visits for suspected suicide. We also
reviewed SAMHSA research bulletins and other documents. In addition,
we reviewed publications by the National Academies of Science,
Engineering, and Medicine about behavioral health during the pandemic.
We also reviewed selected journal articles that identified populations at
risk of, or experiencing, behavioral health conditions or effects. We
identified journal articles through our review of CDC and SAMHSA
publications and other publications; input from federal officials,
Page 58 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
researchers, and other stakeholders; and a targeted literature search. 3
For each of the journal articles cited in this report, we reviewed the study
methodologies and determined that they were suitable for identifying
specific populations at higher risk of behavioral health effects due to the
COVID-19 pandemic.
We also reviewed data from the Census Bureau’s Household Pulse
Survey on populations and the estimated percentage of U.S. adults
reporting symptoms of anxiety disorder and depressive disorder during
the COVID-19 pandemic. 4 We assessed the reliability of these data by
reviewing relevant agency documentation, requesting written information
from agency officials, and checking for obvious errors. We determined
that these data were sufficiently reliable for the purpose of describing
what populations may be at higher risk of behavioral health effects related
to the COVID-19 pandemic.
Information from selected stakeholders. We analyzed input from 32 of
the stakeholders listed above who answered open-ended questions about
3For the targeted literature search, we conducted a search for relevant peer reviewed
literature published between September 1, 2020, and June 1, 2021. We used bibliographic
databases such as MEDLINE, APA PsycInfo, and SciSearch, and search terms such as
“mental health,” “anxiety,” “depress*,” “suicide*,” “substance,” “alcohol,” “overdose,” and
“PTSD.” Given the volume of literature being published on COVID-19 and behavioral
health, we focused the search on terms in the title of journal articles and limited our review
to articles about behavioral health in the United States. We selected articles that were
most relevant to our analysis.
4The Household Pulse Survey, an experimental data product, is an interagency federal
statistical rapid response survey to measure household experiences during the COVID-19
pandemic. The survey is conducted by the Census Bureau in partnership with seven other
agencies from the Federal Statistical System. These estimates are based on responses to
two questions about symptoms of depressive disorder and two questions about symptoms
of anxiety disorder in the prior 7 days. The percentage of adults include those who
reported symptoms that generally occurred more than half the days or nearly every day.
Weighted response rates have ranged from 1.3-10.3 percent, and averaged about 5.8
percent. In March 2021, Census published the results of a nonresponse bias analysis that
identified evidence of response patterns that could result in biased estimates. Census
adjusted sampling weights, which can help but may not completely mitigate nonresponse
bias. See https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm, accessed October
19, 2021; and
https://www.census.gov/programs-surveys/household-pulse-survey/technical-documentati
on.html, accessed October 25, 2021, for more information about the mental health results
and survey methodology.
Page 59 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
the pandemic’s effects on behavioral health. 5 The questions were on
topics such as stakeholders’ most pressing behavioral health concerns
during the pandemic; populations at higher risk, or of particular concern
due to the pandemic, and why; the pandemic’s impact on certain
populations such as health care workers and people with prior behavioral
health conditions; and populations at higher risk after disease outbreaks
and other disasters. The questions varied somewhat depending on
stakeholders’ specific roles and the timing of our outreach to them. We
analyzed stakeholders’ responses across varying questions to determine
whether they identified particular populations as being potentially at
higher risk of behavioral health effects. We grouped certain populations
together into broader populations. For example, we grouped people
experiencing unemployment, housing or food insecurity, low incomes, or
other situations related to financial distress into one broader population
we referred to as “people facing financial distress.” We also grouped
people with serious mental illness, people with substance use disorders,
and other people with behavioral health conditions into one broader
population we referred to as “people with pre-existing behavioral health
conditions.”
Identifying populations that may be at higher risk of behavioral
health effects. For the purpose of identifying populations that may be at
higher risk of behavioral health effects related to COVID-19, we
considered how many stakeholders identified various populations as
potentially being at higher risk, as well as the results of selected research.
We found that the populations identified by stakeholders and research
generally fell into two groups based on the frequency with which particular
populations were cited:
• Stakeholders identified six populations most frequently as potentially
at higher risk. Specifically, four populations that more than half of the
32 stakeholders identified and two populations that were identified by
5These include officials from four of six federal agencies (Administration for Children and
Families, CDC, SAMHSA, and the National Institutes of Health); representatives of the
behavioral and other health care provider associations, consumer groups, and national
associations representing state agencies and American Indian/Alaska Native health
organizations; and researchers. We also included behavioral health agencies in four
states and Washington, D.C. For this analysis, we considered each state to be a single
stakeholder even when we spoke to multiple agencies in a state. We did not consider
input from the other recipients of federal COVID-19 behavioral health relief funding that
were not state agencies, though we include illustrative examples of their input as
appropriate. Officials from two federal agencies—FEMA and the Health Resources and
Services Administration—did not provide input on the populations at higher risk of
behavioral health effects related to the pandemic.
Page 60 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
about half (15 or 16) of stakeholders. Selected research we reviewed
also cited all six populations as potentially at higher risk.
• A smaller share of stakeholders—three to nine—identified 11 other
populations as potentially at higher risk. Selected research also cited
these populations.
We did not include in those two groups—or describe in the report—
populations that were identified by one or two stakeholders. Those
populations included, for example, individuals who experienced the death
of someone in their life due to COVID-19; individuals who are
incarcerated or otherwise involved with the criminal justice system; and
individuals with disabilities. The populations we describe in the report are
not meant to be exhaustive of all populations at higher risk of behavioral
health effects due to the pandemic, but rather reflect stakeholder input
and selected research. There may be additional populations at higher
risk.
Analysis of Federal To further determine the amount and type of COVID-19 relief funding for
Government COVID-19 behavioral health the federal government provided and whether the
funding could serve higher-risk populations, we reviewed relevant federal
Relief Funding for
laws and agency documents, COVID-19 funding opportunity documents
Behavioral Health for behavioral health, and award documentation for SAMHSA and FEMA
program funds awarded after the CARES Act was enacted in March 2020
through November 2021. We reviewed funding opportunity documents to
determine such things as grant purposes, time frames, and populations of
focus. We also interviewed or obtained written responses from SAMHSA
and FEMA about, among other things, how the agencies
• made funding decisions,
• communicated funding opportunities and any updates to programs,
and
• responded to challenges reported by funding recipients related to
using relief funds.
To determine the reliability of the data—SAMHSA and FEMA funding and
award information—we interviewed agency officials, reviewed relevant
documentation, and checked for obvious errors. We determined the data
were sufficiently reliable for reporting on the amount and type of funding
the federal government provided for COVID-19 relief funding for
behavioral health to states, providers, and other organizations.
Page 61 GAO-22-104437 Behavioral Health and COVID-19
Appendix I: Objectives, Scope, and
Methodology
We conducted this performance audit from July 2020 through December
2021 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
Page 62 GAO-22-104437 Behavioral Health and COVID-19
Appendix II: Other Populations Stakeholders
Appendix II: Other Populations Stakeholders
Identified as Potentially Being at Higher Risk of
Behavioral Health Effects
Identified as Potentially Being at Higher Risk
of Behavioral Health Effects
When identifying populations that may be at higher risk of behavioral
health effects due to the Coronavirus Disease 2019 (COVID-19)
pandemic, we identified two groups of populations: (1) six populations
that stakeholders identified most frequently as potentially at higher risk,
and (2) other populations that a small share of stakeholders (three to
nine) identified as being potentially at higher risk. 1 This appendix provides
information about the behavioral health risks for these other populations.
The populations we describe in table 8 are not meant to be exhaustive of
all other higher-risk populations, but rather reflect stakeholder input and
selected research.
1The six populations most frequently cited populations were people from certain racial and
ethnic groups; health care workers; children and adolescents; people with pre-existing
behavioral health conditions; young adults; and people facing financial distress. They
included four populations that more than half of the 32 stakeholders included in this
analysis identified, and two populations that were identified by about half (15 or 16) of
those stakeholders. We did not include populations if they were identified by one or two
stakeholders. Examples include individuals who experienced the death of someone in
their life due to COVID-19; individuals who are incarcerated or otherwise involved with the
criminal justice system; and individuals with disabilities.
Page 63 GAO-22-104437 Behavioral Health and COVID-19
Appendix II: Other Populations Stakeholders
Identified as Potentially Being at Higher Risk of
Behavioral Health Effects
Table 8: Other Populations Stakeholders Identified as Potentially Being at Higher Risk of Behavioral Health Effects Related to
the COVID-19 Pandemic
Population Examples of stakeholder input and research on behavioral health risks
Women Nine stakeholders identified women as potentially at higher risk of behavioral health effects due to the
pandemic, citing factors such as increased childcare responsibilities and job loss. Pregnant women in particular
were identified by some stakeholders as being at higher risk. A Substance Abuse and Mental Health Services
Administration (SAMHSA) research bulletin reported that studies conducted in 2020 found higher levels of
anxiety, depression, and traumatic stress among women than in men; studies also found that women’s
consumption of alcohol increased during the pandemic.a
Centers for Disease Control and Prevention (CDC) officials cited findings from the Household Pulse Survey,
which has consistently found that women report higher rates of symptoms of anxiety disorder or depressive
disorder than men. From August 18 – August 30, 2021, 36 percent of women reported such symptoms, as
compared with 28 percent of men.b
Members of a research group told us that women are generally more likely than men to experience anxiety and
depression, and that women are more likely than men to experience those symptoms after a disaster or crisis.
They said it can be difficult to distinguish the pandemic’s effect on women from pre-pandemic patterns.
Older adults Nine stakeholders raised concerns about older adults, such as those with cognitive impairments or who live in a
nursing home. Some stakeholders said that social isolation could be contributing to poor behavioral health
effects in this population. For example, the head of a behavioral health clinic in one state said concerns
regarding this group had not been discussed enough during the pandemic. The clinic’s elderly patients had to
isolate during the pandemic, and some did not have good social supports; for example, their families had not
been able to check on them. She expected that elderly patients would eventually return to the clinic with
exacerbated psychiatric conditions.
One researcher noted that while surveys conducted during the pandemic have found older adults to be faring
less poorly than younger adults, those surveys may not be capturing certain older adults, such as those lacking
access to technology. Further, there might be groups of older adults that are at higher risk of experiencing
behavioral health problems, even though it is not apparent in aggregate survey data. A SAMHSA research
bulletin stated that while older adults generally seemed to be faring better than other age groups, it was unclear
whether this difference would hold over time.a
Parents of young Seven stakeholders identified this population as particularly at risk, in part, due to the stress parents
or school-aged experienced due to children learning from home during the pandemic. Officials in one jurisdiction said parents
children faced challenges managing work, family life, and being teachers for children learning from home. One
researcher anticipated negative mental health outcomes for parents of small children, but said there was not
robust data on the behavioral health of this population.
A study examining the mental health of adult caregivers—specifically, parents of children under age 18 and
unpaid caregivers of adults—found that parents reported significantly worse mental health than adults without
any caregiving role. According to survey data from December 6–27, 2020, and February 16–March 8, 2021,
parents were more likely than non-caregivers to report symptoms of anxiety or depression, or suicidal ideation.c
People who were Seven stakeholders raised concerns about this population. National Institutes of Health officials and a SAMHSA
diagnosed with research bulletin cited research that found individuals diagnosed with COVID-19 were more likely than
COVID-19 individuals diagnosed with several other illnesses to develop a new psychiatric diagnosis. The most common
new diagnoses were anxiety disorders, followed by mood disorders.a Some stakeholders noted that it is still too
early to tell what the implications of a COVID-19 diagnosis are for behavioral health.
Page 64 GAO-22-104437 Behavioral Health and COVID-19
Appendix II: Other Populations Stakeholders
Identified as Potentially Being at Higher Risk of
Behavioral Health Effects
Population Examples of stakeholder input and research on behavioral health risks
Essential workers Five stakeholders cited risks facing this population. Some stakeholders pointed to survey data from June 2020
that found self-reported essential workers reported higher rates of suicidal ideation, starting or increased
substance use to cope with pandemic-related stress, and symptoms of anxiety disorder or depressive disorder
than people who were not essential workers. CDC reported, for example, that the percentage of adults who
reported having seriously considered suicide in the 30 days before completing the survey (10.7 percent overall)
was significantly higher among essential workers (21.7 percent).d
Two stakeholders said grocery story workers and others who must be in public due to their jobs might be
particularly at risk of behavioral health effects, because their jobs place them at increased exposure to COVID-
19.
Individuals who Five stakeholders raised concerns about this population. A psychiatric nurses’ association said these
are lesbian, gay, individuals were at higher risk of depression and suicide before the pandemic and that pandemic-related
bisexual, or isolation could have led to worsening depression and suicidal ideation. Officials in one state similarly said that
transgender these individuals could experience worsening behavioral health symptoms—and added that it can be difficult for
them to access culturally competent behavioral health resources.
People with fewer Five stakeholders identified this population as particularly at risk, with some citing the potential impact of
social supports pandemic-driven social isolation. One researcher noted that before the pandemic, social isolation and
loneliness were linked to poorer behavioral health outcomes, such as depression and anxiety, as well as
cognitive decline. Members of a research group noted that in times of crisis a person’s degree of social support
affects their risk for behavioral health symptoms, and that social supports—which the pandemic undercut—
serve as a protective factor. Officials in one state said they were worried about people who were living alone
and experiencing extreme isolation and loneliness.
People Five stakeholders cited risks facing this population. According to SAMHSA, the economic stress, disconnection
experiencing from community resources, and uncertainty stemming from the COVID-19 pandemic can lead to violence in
domestic violence families where it did not exist before—and worsen situations in homes where violence was already a problem.e
The pandemic also made it more difficult to seek help or leave a violent situation. Administration for Children
and Families officials noted that shelters and other services had often been unavailable or significantly limited
due to pandemic precautions, and that abusers consistently being at home led to fewer opportunities for people
to leave the abusive situation. The head of a behavioral health clinic in one state said people were likely having
to stay longer in very bad situations, because they could not find a safe time to leave their abuser, they had no
safe place to go, or the people and places that would otherwise take them in would not do so due to the
pandemic.
People living in Three stakeholders raised concerns about this population, due, in part, to challenges rural populations face in
rural areas accessing mental health care services. Members of a research group told us that the lack of mental health
providers in rural areas can lead to months-long wait times for appointments and hinder individuals’ ability to
have their behavioral health conditions assessed, diagnosed, and treated.
A 2020 study assessed the pandemic’s impact on the well-being of individuals in the North American West, to
help address a gap in knowledge about how diverse rural communities were faring during the pandemic. In
particular, about 44 percent of respondents reported that the pandemic had some level of negative impact on
their mental health, compared to 56 percent who reported no impact or a positive impact on their mental health.f
Unpaid caregivers Three stakeholders identified this population, citing survey data from June 2020 that found self-reported unpaid
of adults caregivers of adults reported higher rates of increased substance use to cope with pandemic-related stress,
suicidal ideation, and symptoms of anxiety disorder or depressive disorder than people who were not unpaid
caregivers. CDC reported that among unpaid caregivers, 32.9 percent reported increased substance use and
30.7 percent reported suicidal ideation. Among adults who were not unpaid caregivers, 6.3 percent reported
increased substance use and 3.6 percent reported suicidal ideation.d
A more recent study examining the mental health of adult caregivers—specifically, parents of children under
age 18 and unpaid caregivers of adults—found that unpaid caregivers of adults reported significantly worse
mental health than adults without any caregiving role. According to survey data from December 6–27, 2020,
and February 16–March 8, 2021, unpaid caregivers of adults were more likely than non-caregivers to report
symptoms of anxiety or depression, or suicidal ideation.c
Page 65 GAO-22-104437 Behavioral Health and COVID-19
Appendix II: Other Populations Stakeholders
Identified as Potentially Being at Higher Risk of
Behavioral Health Effects
Population Examples of stakeholder input and research on behavioral health risks
People with limited Three stakeholders identified this population. CDC officials cited findings from the Census Bureau’s Household
education Pulse Survey, which has generally found that people with less than a high school education reported higher
rates of symptoms of anxiety disorder or depressive disorder that people with higher levels of education. From
August 18 – August 30, 2021, 36.3 percent of people with less than a high school diploma reported such
symptoms, as compared with 27.1 percent of people with a Bachelor’s degree or higher.b
Source: GAO analysis of stakeholder input and selected research. | GAO-22-104437
a
Substance Abuse and Mental Health Services Administration, Disaster Technical Assistance Center
Supplemental Research Bulletin: A Preliminary Look at the Mental Health and Substance Use-related
Effects of the COVID-19 Pandemic, (Rockville, Md.: May 2021).
b
The Household Pulse Survey, an experimental data product, is an interagency federal statistical
rapid response survey to measure household experiences during the COVID-19 pandemic. These
estimates are based on responses to two questions about symptoms of depressive disorder and two
questions about symptoms of anxiety disorder in the prior 7 days. The percentage of adults include
those who reported symptoms that generally occurred more than half the days or nearly every day.
The margin of error for these estimates varied, but ranged from about ± 1 to 4 percentage points at
the 95 percent confidence level. See appendix I for details on the Household Pulse Survey and these
estimates, including response rates and nonresponse bias analysis.
c
M. É. Czeisler, E.A.Rohan, S. Melillo et al., Mental Health Among Parents of Children Aged <18
Years and Unpaid Caregivers of Adults During the COVID-19 Pandemic — United States, December
2020 and February–March 2021, MMWR Morbidity and Mortality Weekly Report, vol. 70, no. 24
(2021) (Atlanta, Ga.: Centers for Disease Control and Prevention, June 18, 2021).
d
M. É. Czeisler, R. I. Lane, E. Petrosky et al., Mental Health, Substance Use, and Suicidal Ideation
During the COVID-19 Pandemic — United States, June 24–30, 2020, MMWR Morbidity and Mortality
Weekly Report, vol. 69, no. 32 (2020): p. 1049-1057 (Atlanta, Ga.: Centers for Disease Control and
Prevention, Aug. 14, 2020).
e
Substance Abuse and Mental Health Services Administration, Intimate Partner Violence and Child
Abuse Considerations During COVID-19, (Rockville, Md.: April 2020).
f
J. T. Mueller, K. McConnell, P.B. Burow et al, “Impacts of the COVID-19 Pandemic on Rural
America,” Proceedings of the National Academy of Sciences, vol. 118, no. 1 (Jan. 5, 2021).
Page 66 GAO-22-104437 Behavioral Health and COVID-19
Appendix III: Challenges in Assessing the
Appendix III: Challenges in Assessing the
COVID-19 Pandemic’s Effects on Behavioral
Health
COVID-19 Pandemic’s Effects on Behavioral
Health
This appendix provides information about the challenges assessing the
COVID-19 pandemic’s effects on behavioral health in the United States,
according to stakeholders and selected research. Some challenges, such
as pandemic-driven changes in data collection methods, stemmed from
the pandemic itself. Other challenges pertained more broadly to
assessments of behavioral health, regardless of the pandemic. (See table
9.)
Table 9: Challenges in Assessing the COVID-19 Pandemic’s Effect on Behavioral Health
Type of challenge Examples
Gaps and limitations Children and adolescents. There are fewer data and published studies on how they have fared than there
in data on certain are on adults, according to some stakeholders. Some national surveys, for example, have not included people
populations under age 18.
Older adults. Some stakeholders said that pandemic-era surveys that are done online or otherwise rely on
technology are not capturing information from older adults who are unable or do not want to participate in
those types of surveys. Representatives of a geriatric behavioral health association said some older adults,
such as those with cognitive deficits, would not be “good reporters” of symptoms, particularly on surveys. They
said older adults’ behavioral health is better assessed with caregiver input; clinician observations and
interviews; and assessments of their ability to do activities of daily living, such as eat and dress.
American Indian/Alaska Native individuals. Representatives of a national group representing American
Indian/Alaska Native communities told us that there is a lack of data on American Indian/Alaska Native
individuals’ behavioral health. They said, for example, that American Indian/Alaska Native individuals may be
included in the category of “other” race and ethnicities, and that behavioral health data are not always reported
separately for the American Indian/Alaska Native population.
People without access to the internet or technology. National Institutes of Health officials said a key
challenge stems from studies having to pivot to collect data in ways that are in line with public health mitigation
efforts. For example, researchers moved from collecting data in-person to collecting it remotely, typically
through online platforms. This presented a new challenge in reaching people with little or no internet access.
Other populations. People with serious mental illness, who are homeless, or who are in nursing homes may
be underrepresented in available survey data, according to stakeholders.
Other data gaps and Data lags. Data on suicides often lag due to the time needed to adjudicate cause of death, which has been
limitations exacerbated by competing demands for medical examiners to determine COVID-19 related deaths, according
to National Institutes of Health officials. Data on drug overdose deaths also lag, as these deaths often require
lengthy investigations and death certificates may be initially filed with a preliminary or unknown cause of
death, according to the Centers for Disease Control and Prevention.a
Limits of self-reported symptoms. Substance Abuse and Mental Health Services Administration (SAMHSA)
has noted that studies based on surveys of self-reported symptoms do not reflect whether a respondent meets
the diagnostic criteria for a behavioral health condition, which requires a more thorough assessment.b
Limits of aggregate data. One researcher noted that aggregate data on populations may obscure the
behavioral health of subgroups that are faring relatively poorly. This may be true, for example, for groups of
older adults whose behavioral health is worse than what is apparent from looking at the data for older adults
as a whole, the researcher said.
Lack of information about people who are not seeking care. Some stakeholders said there have been
gaps in information about children who became disconnected from school supports, people in domestic abuse
situations who were isolated and had not sought assistance, people with new-onset symptoms who had not
yet sought care, and people who stopped accessing care in person due to COVID-19 and had not yet returned
to be seen.
Page 67 GAO-22-104437 Behavioral Health and COVID-19
Appendix III: Challenges in Assessing the
COVID-19 Pandemic’s Effects on Behavioral
Health
Additional challenges State data issues. Officials with one state told us that fragmented behavioral health data created challenges
in assessing behavioral health during the pandemic. Officials with another state told us that in addition to the
inherent difficulty of doing behavioral health surveillance, state epidemiologists also had to work on COVID-19
issues instead of behavioral health.
Research lags. There are lags in published pandemic research due to the time required for data collection,
analysis, reporting, review, and publishing, according to SAMHSA.b
Limits of point-in-time studies. While useful, these types of studies cannot determine the extent to which the
prevalence of behavioral health symptoms and conditions may reflect pre-pandemic rates and trends rather
than the pandemic’s impact, according to some stakeholders.
Concurrent national and regional factors. Some stakeholders noted that during the pandemic there have
been additional factors that have potentially affected peoples’ behavioral health, such as wildfires and the
political climate; this makes it difficult to distinguish the pandemic’s impact from the impact of other factors,
according to some researchers.
Source: GAO analysis of stakeholder input and selected research. | GAO-22-104437
a
F.B. Ahmad, L.M. Rossen LM, and P. Sutton, National Center for Health Statistics, Centers for
Disease Control and Prevention, Provisional Drug Overdose Death Counts, accessed August 24,
2021, https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm.
b
Substance Abuse and Mental Health Services Administration, Disaster Technical Assistance Center
Supplemental Research Bulletin: A Preliminary Look at the Mental Health and Substance Use-related
Effects of the COVID-19 Pandemic, (Rockville, Md.: May 2021).
Page 68 GAO-22-104437 Behavioral Health and COVID-19
Appendix IV: Block Grant Awards Provided
Appendix IV: Block Grant Awards Provided
from COVID-19 Relief Funds for Behavioral
Health
from COVID-19 Relief Funds for Behavioral
Health
This appendix presents supplemental grant amounts awarded from
COVID-19 relief funds through the Substance Abuse and Mental Health
Services Administration’s Community Mental Health Services Block Grant
and Substance Abuse Prevention and Treatment Block Grant. 1 (See
tables 10 and 11, respectively.)
Table 10: Community Mental Health Services Block Grant (MHBG) Supplemental Award Amounts from COVID-19 Relief Funds
by State, U.S. Territory, or Jurisdiction
Dollars
Consolidated American Rescue Plan Per capita
State, territory, or jurisdiction Appropriations Act, 2021 Act of 2021 Total funding amount
Alabama 11,944,986 20,632,249 32,577,235 6.62
Alaska 1,869,289 3,228,772 5,098,061 6.97
American Samoa 162,398 280,505 442,903 9.55
Arizona 22,711,565 39,229,067 61,940,632 8.35
Arkansas 7,229,333 12,487,030 19,716,363 6.51
California 108,247,196 186,972,433 295,219,629 7.50
Colorado 16,240,446 28,051,679 44,292,125 7.63
Connecticut 8,012,502 13,839,776 21,852,278 6.14
Delaware 1,925,871 3,326,504 5,252,375 5.32
Federated States of Micronesia 331,157 571,998 903,155 8.88
Florida 54,888,469 94,807,356 149,695,825 6.89
Georgia 26,439,839 45,668,812 72,108,651 6.73
Guam 536,059 925,921 1,461,980 8.66
Hawaii 4,161,536 7,188,108 11,349,644 8.07
Idaho 4,873,385 8,417,665 13,291,050 7.28
Illinois 29,073,007 50,217,012 79,290,019 6.30
Indiana 14,807,647 25,576,844 40,384,491 5.98
Iowa 6,483,317 11,198,457 17,681,774 5.59
Kansas 6,035,542 10,425,027 16,460,569 5.65
Kentucky 10,734,798 18,541,924 29,276,722 6.54
Louisiana 11,975,406 20,684,792 32,660,198 7.03
Maine 3,241,688 5,599,279 8,840,967 6.55
1CARES Act, Pub. L. No. 116-136, div. B., tit. VIII, 134 Stat. 281, 556 (2020);
Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, div. M, tit. III, 134 Stat. 1182,
1913 (2020); American Rescue Plan Act of 2021, Pub. L. No. 117-2, tit. II, subtit. H, 135
Stat. 4, 45-48. Unless otherwise stated, references to the Consolidated Appropriations
Act, 2021 in this report refer to Division M of that act (Coronavirus Response and Relief
Supplemental Appropriations Act, 2021).
Page 69 GAO-22-104437 Behavioral Health and COVID-19
Appendix IV: Block Grant Awards Provided
from COVID-19 Relief Funds for Behavioral
Health
Consolidated American Rescue Plan Per capita
State, territory, or jurisdiction Appropriations Act, 2021 Act of 2021 Total funding amount
Maryland 16,100,385 27,809,755 43,910,140 7.25
Massachusetts 16,551,534 28,589,013 45,140,547 6.55
Michigan 24,265,829 41,913,705 66,179,534 6.64
Minnesota 12,518,067 21,622,115 34,140,182 6.03
Mississippi 7,556,583 13,052,279 20,608,862 6.95
Missouri 13,913,837 24,032,991 37,946,828 6.17
Montana 2,531,162 4,372,007 6,903,169 6.39
Nebraska 3,795,400 6,555,690 10,351,090 5.34
Nevada 8,743,742 15,102,828 23,846,570 7.60
New Hampshire 2,912,959 5,031,475 7,944,434 5.81
New Jersey 22,649,212 39,121,366 61,770,578 6.95
New Mexico 5,026,824 8,682,696 13,709,520 6.51
New York 46,339,285 80,040,583 126,379,868 6.54
North Carolina 24,046,721 41,535,246 65,581,967 6.19
North Dakota 1,435,102 2,478,813 3,913,915 5.11
Northern Mariana Islands 166,129 286,951 453,080 8.77
Ohio 25,773,140 44,517,241 70,290,381 6.01
Oklahoma 9,094,136 15,708,052 24,802,188 6.23
Oregon 13,107,788 22,640,725 35,748,513 8.43
Palau 68,747 118,745 187,492 8.67
Pennsylvania 27,119,409 46,842,615 73,962,024 5.79
Puerto Rico 10,526,878 18,182,788 28,709,666 9.09
Marshall Islands 241,823 417,694 659,517 8.37
Rhode Island 3,069,963 5,302,664 8,372,627 7.92
South Carolina 12,436,240 21,480,779 33,917,019 6.50
South Dakota 1,782,520 3,078,898 4,861,418 5.45
Tennessee 15,793,941 27,280,443 43,074,384 6.25
Texas 74,580,936 128,821,616 203,402,552 6.93
Utah 7,459,411 12,884,438 20,343,849 6.26
Vermont 1,415,844 2,445,549 3,861,393 6.19
Virgin Islands 341,809 590,398 932,207 8.81
Virginia 20,718,461 35,786,432 56,504,893 6.58
Washington 19,222,372 33,202,279 52,424,651 6.81
Washington, D.C. 1,956,394 3,379,225 5,335,619 7.49
West Virginia 4,503,493 7,778,761 12,282,254 6.88
Wisconsin 14,259,851 24,630,652 38,890,503 6.67
Page 70 GAO-22-104437 Behavioral Health and COVID-19
Appendix IV: Block Grant Awards Provided
from COVID-19 Relief Funds for Behavioral
Health
Consolidated American Rescue Plan Per capita
State, territory, or jurisdiction Appropriations Act, 2021 Act of 2021 Total funding amount
Wyoming 1,048,637 1,811,283 2,859,920 4.91
Total 825,000,000 1,425,000,000 2,250,000,000
Source: GAO analysis of Substance Abuse and Mental Health Services Administration and U.S. Census Bureau documentation. | GAO-22-104437
Note: Per capita funding is based on U.S. Census Bureau July 2020 population estimates for states
and Puerto Rico, and July 2021 estimates for U.S. territories and other jurisdictions.
Table 11: Substance Abuse Prevention and Treatment Block Grant (SABG) Supplemental Award Amounts from COVID-19
Relief Funds by State, U.S. Territory, Jurisdiction, or Tribe
Dollars
State, territory, jurisdiction Consolidated American Rescue
or tribe Appropriations Act, 2021 Plan Act of 2021 Total Per capita amount
Alabama 21,641,962 18,690,785 40,332,747 8.20
Alaska 5,519,877 4,767,166 10,287,043 14.07
American Samoa 324,795 280,505 605,300 13.05
Arizona 37,892,228 32,725,106 70,617,334 9.52
Arkansas 12,676,621 10,947,991 23,624,612 7.80
California 238,465,012 205,947,056 444,412,068 11.29
Colorado 27,102,042 23,406,309 50,508,351 8.70
Connecticut 17,070,466 14,742,675 31,813,141 8.94
Delaware 6,530,972 5,640,385 12,171,357 12.33
Federated States of Micronesia 662,313 571,998 1,234,311 12.14
Florida 104,396,719 90,160,803 194,557,522 8.95
Georgia 53,569,236 46,264,340 99,833,576 9.32
Guam 1,072,119 925,921 1,998,040 11.84
Hawaii 8,044,183 6,947,249 14,991,432 10.65
Idaho 8,000,710 6,909,704 14,910,414 8.16
Illinois 63,404,936 54,758,808 118,163,744 9.39
Indiana 30,224,518 26,102,993 56,327,511 8.34
Iowa 12,272,501 10,598,978 22,871,479 7.23
Kansas 11,153,650 9,632,698 20,786,348 7.13
Kentucky 19,100,815 16,496,159 35,596,974 7.95
Louisiana 23,457,477 20,258,730 43,716,207 9.41
Maine 6,530,972 5,640,385 12,171,357 9.01
Maryland 31,943,446 27,587,522 59,530,968 9.83
Massachusetts 37,347,121 32,254,331 69,601,452 10.10
Michigan 52,538,794 45,374,413 97,913,207 9.82
Page 71 GAO-22-104437 Behavioral Health and COVID-19
Appendix IV: Block Grant Awards Provided
from COVID-19 Relief Funds for Behavioral
Health
State, territory, jurisdiction Consolidated American Rescue
or tribe Appropriations Act, 2021 Plan Act of 2021 Total Per capita amount
Minnesota 22,591,036 19,510,440 42,101,476 7.44
Mississippi 12,938,191 11,173,892 24,112,083 8.13
Missouri 24,884,101 21,490,814 46,374,915 7.54
Montana 6,530,972 5,640,385 12,171,357 11.26
Nebraska 7,162,196 6,185,533 13,347,729 6.89
Nevada 15,937,418 13,764,133 29,701,551 9.46
New Hampshire 6,530,972 5,640,385 12,171,357 8.91
New Jersey 45,050,958 38,907,646 83,958,604 9.45
New Mexico 8,965,458 7,742,896 16,708,354 7.93
New York 104,819,223 90,525,693 195,344,916 10.10
North Carolina 42,171,280 36,420,651 78,591,931 7.41
North Dakota 6,123,948 5,288,864 11,412,812 14.91
Northern Mariana Islands 332,259 286,951 619,210 11.99
Ohio 60,489,869 52,241,251 112,731,120 9.64
Oklahoma 16,074,216 13,882,277 29,956,493 7.53
Oregon 19,288,251 16,658,035 35,946,286 8.47
Palau 137,494 118,745 256,239 11.86
Pennsylvania 55,395,098 47,841,221 103,236,319 8.08
Puerto Rico 21,053,755 18,182,788 39,236,543 12.42
Red Lake Band of Chippewa 556,786 480,861 1,037,647 N/Aa
Indians
Marshall Islands 483,646 417,694 901,340 11.43
Rhode Island 7,122,113 6,150,916 13,273,029 12.56
South Carolina 22,230,862 19,199,380 41,430,242 7.94
South Dakota 5,662,944 4,890,725 10,553,669 11.82
Tennessee 29,973,471 25,886,179 55,859,650 8.11
Texas 135,636,613 117,140,711 252,777,324 8.61
Utah 15,548,611 13,428,346 28,976,957 8.92
Vermont 6,054,892 5,229,225 11,284,117 18.10
Virgin Islands 683,619 590,398 1,274,017 12.03
Virginia 39,348,104 33,982,454 73,330,558 8.54
Washington 35,415,872 30,586,435 66,002,307 8.58
Washington, D.C. 6,530,972 5,640,385 12,171,357 17.08
West Virginia 7,904,019 6,826,198 14,730,217 8.25
Wisconsin 25,492,891 22,016,587 47,509,478 8.15
Wyoming 3,934,405 3,397,896 7,332,301 12.59
Total 1,650,000,000 1,425,000,000 3,075,000,000
Page 72 GAO-22-104437 Behavioral Health and COVID-19
Appendix IV: Block Grant Awards Provided
from COVID-19 Relief Funds for Behavioral
Health
Source: GAO analysis of Substance Abuse and Mental Health Services Administration and U.S. Census Bureau documentation. | GAO-22-104437
Note: Per capita funding is based on U.S. Census Bureau July 2020 population estimates for states
and Puerto Rico, and July 2021 estimates for U.S. territories and other jurisdictions.
a
A current population estimate for the Red Lake Band of Chippewa Indians was not available.
Page 73 GAO-22-104437 Behavioral Health and COVID-19
Appendix V: Crisis Counseling Assistance
Appendix V: Crisis Counseling Assistance and
Training Program Awards for COVID-19 Relief
and Training Program Awards for COVID-19
Relief
This appendix presents the amounts awarded for COVID-19 relief through
the Federal Emergency Management Agency’s Crisis Counseling
Assistance and Training Program (CCP). (See table 12.) The CCP was
available to states, Washington, D.C., U.S. territories, and tribes through
two grant mechanisms: (1) the Immediate Services Program, which
provides funds for up to 60 days of services immediately following a
disaster declaration, with options for extensions; and (2) the Regular
Services Program, which provides funds for up to 9 months following the
date the recipients received the notice of award, with options for
extensions. 1
Table 12: Crisis Counseling Assistance and Training Program Approved Award Amounts by State and Territory as of
November 2021
Dollars
Immediate Services Regular Services
State Program Program Total Per capita amount
Alabama Did not apply 3,698,690 3,698,690 0.75
Alaska Did not apply Withdrew application 0.00 0.00
Arizona 976,751 3,333,221 4,309,972 0.58
Arkansas 961,620 4,523,036 5,484,656 1.81
California 3,755,732 106,204,594 109,960,326 2.79
Colorado 1,780,587 12,544,342 14,324,929 2.47
Connecticut 704,039 3,080,526 3,784,565 1.06
Delaware 281,651 1,229,750 1,511,401 1.53
Florida Did not apply 4,994,530 4,994,530 0.23
Georgia 398,978 1,735,482 2,134,460 0.20
Guam Did not apply 993,186 993,186 5.88
Hawaii 127,850 2,102,679 2,230,529 1.59
Idaho 382,643 1,798,634 2,181,277 1.19
Illinois Did not apply 2,249,090 2,249,090 0.18
Indiana 986,244 3,862,696 4,848,940 0.72
Iowa 1,400,566 4,743,732 6,144,298 1.94
Kansas 217,825 2,202,452 2,420,277 0.83
1States, U.S. territories, and tribes were eligible to apply for and receive funds if (1) the
disaster crisis counseling needs for the COVID-19 pandemic were beyond the combined
capabilities of the state, territorial, or tribal governments to address; (2) the total number of
COVID-19 cases exceeded 5,000 within the state, territory or tribe, or the total of number
of COVID-19 cases exceeded 1,000 per 1 million of the population; (3) the state, tribe, or
territory had mandatory closure orders of schools, places of employment, and social
service networks due to health and safety concerns of the population; and (4) data existed
to demonstrate heightened need for emotional care.
Page 74 GAO-22-104437 Behavioral Health and COVID-19
Appendix V: Crisis Counseling Assistance and
Training Program Awards for COVID-19 Relief
Immediate Services Regular Services
State Program Program Total Per capita amount
Kentucky Did not apply Did not apply 0.00 0.00
Louisiana 1,997,742 7,722,778 9,720,520 2.09
Maine 989,045 3,789,247 4,778,292 3.54
Maryland 90,000 537,800 627,800 0.10
Massachusetts 707,507 3,780,904 4,488,411 0.65
Michigan 371,983 2,870,421 3,242,404 0.33
Minnesota 537,651 1,826,991 2,364,642 0.42
Mississippi Did not apply Did not apply 0.00 0.00
Missouri 2,277,507 12,920,042 15,197,549 2.47
Montana Withdrew application 1,642,155 1,642,155 1.52
Navajo Nation Did not apply Application under review 0.00 0.00
Nebraska 1,461,165 5,326,327 6,787,492 3.50
Nevada 654,640 2,750,183 3,404,823 1.08
New Hampshire 120,925 212,845 333,770 0.24
New Jersey 1,308,969 11,628,711 12,937,680 1.46
New Mexico 798,899 3,625,473 4,424,372 2.10
New York 1,315,111 106,818,771 108,133,882 5.59
North Carolina 1,567,261 3,604,753 5,172,014 0.49
North Dakota 251,053 835,629 1,086,682 1.42
Northern Mariana Islands 113,854 986,443 1,100,297 21.30
Ohio 466,550 6,350,924 6,817,474 0.58
Oklahoma 521,685 5,701,193 6,222,878 1.56
Oregon Withdrew application 10,344,256 10,344,256 2.44
Pennsylvania 754,391 1,126,157 1,880,548 0.15
Poarch Band Creek Indians Did not apply Did not apply 0.00 0.00
Puerto Rico 3,214,047 18,437,618 21,651,665 6.85
Rhode Island 209,979 1,455,469 1,665,448 1.58
South Carolina 311,588 3,599,354 3,910,942 0.75
South Dakota 210,723 681,872 892,595 1.00
Tennessee 966,380 3,494,302 4,460,682 0.65
Texas 5,862,529 20,686,221 26,548,750 0.90
Utah 1,419,476 3,277,676 4,697,152 1.45
Vermont 140,645 1,095,186 1,235,831 1.98
Virgin Islands 295,585 929,116 1,224,701 11.57
Virginia 391,655 996,016 1,387,671 0.16
Washington 2,194,956 6,065,389 8,260,345 1.07
Page 75 GAO-22-104437 Behavioral Health and COVID-19
Appendix V: Crisis Counseling Assistance and
Training Program Awards for COVID-19 Relief
Immediate Services Regular Services
State Program Program Total Per capita amount
Washington, D.C. 350,507 3,525,592 3,876,099 5.44
West Virginia 123,500 937,891 1,061,391 0.59
Wisconsin 675,526 3,931,117 4,606,643 0.79
Wyoming Did not apply Did not apply 0.00 0.00
Total 44,647,520 422,811,462 467,458,982
Source: GAO analysis of Federal Emergency Management Agency (FEMA) and U.S. Census Bureau documentation. | GAO-22-104437
Notes: Per capita funding is based on U.S. Census Bureau July 2020 population estimates for states
and Puerto Rico, and July 2021 estimates for U.S. territories and other jurisdictions.
According to FEMA officials, recipients requested a specific amount of funding to address their
disaster specific needs and provided a written narrative and a budget to justify that amount. The
amount of funding FEMA awarded to recipients was based on several factors including (1) the
amount of funding requested; (2) the justification provided; (3) the demonstrated need for the
services; and (4) the recipient’s capability to provide services.
According to FEMA officials, states are not required to share their reasons for not applying for a
program or for withdrawing an application. However, some reasons included declining to apply due to
sufficient resources existing within the state or tribe to meet the need, or determining that the need is
not great enough to require a FEMA program. Additionally, receiving Immediate Services Program
funding is not a prerequisite for Regular Services Program funding, and some states, tribes, or
territories may decide to apply just for the Regular Services Program and not the Immediate Services
Program, or vice versa, based on the availability of resources or population need.
Page 76 GAO-22-104437 Behavioral Health and COVID-19
Appendix VI: GAO Contact and Staff
Appendix VI: GAO Contact and Staff
Acknowledgements
Acknowledgements
Alyssa M. Hundrup, (202) 512-7114, HundrupA@gao.gov.
GAO Contact
In addition to the contact named above, the following individuals made
Staff key contributions to this report: Karen Doran (Assistant Director),
Acknowledgements Christina Ritchie (Analyst-in-Charge), Robin Burke, and Kaitlin Dunn.
Joycelyn Cudjoe, Drew Long, Eric Peterson, Vikki Porter, Patricia Powell,
and Emily Wilson Schwark provided technical and other support.
(104437)
Page 77 GAO-22-104437 Behavioral Health and COVID-19
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