Summary

Substance use disorder and overdose, suicide, and youth mental illness are major public health crises that cost the United States in lives, human potential, productivity, and resources. Government agencies at the federal, state, tribal, and local levels work together with health care entities, academic institutions, communities, and community-based organizations to respond to these crises largely with treatment and recovery services. Mental, emotional, and behavioral (MEB) disorders are mental and substance use disorders and associated problem behaviors, even if they do not meet diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Less attention and fewer resources are dedicated to delivering services specifically devoted to preventing such disorders and promoting MEB health and overall well-being. Greater support for prevention could minimize the pain and suffering associated with MEB disorders, and, critically, reduce the burden on overtaxed treatment and recovery systems.

This report provides a blueprint to develop the infrastructure to deliver programs that reduce risk factors (characteristics associated with a higher likelihood of negative outcomes) and promote protective factors (characteristics that can reduce the negative impact of a risk factor and promote better outcomes) for MEB disorders across the life course and in an array of settings. The committee’s charge was to outline the components and requirements of a well-functioning infrastructure to support the delivery of evidence-based programs at federal, state, tribal, and local levels.

The committee focused on the following infrastructure components and has organized its analysis accordingly:

• Evidence-based programs that are continually evaluated and well-disseminated, with easily accessed details about their effectiveness (including generalizability to other populations) and implementation (Chapter 2);
• A workforce that is sufficiently trained to deliver those strategies, representative of the populations served and able to provide linguistically and culturally appropriate services, fairly paid, and supported with opportunities for career advancement (Chapter 3);
• Data systems that are sufficient for informing needs assessments (including for collecting data about subpopulations to monitor inequities across racial, ethnic, tribal, low-income, and rural communities), selecting strategies, and supporting evaluation and accountability (Chapter 4);
• Governance structures at the federal, state, tribal, and local levels that maximize strategies to ensure shared leadership through cross-sector and community partnerships (Chapter 5);
• Funding that is adequate and sustainable (Chapter 6);
• Evidence-based policies that create and strengthen the social, economic, and environmental conditions necessary for MEB disorder prevention and undergird population health (Chapter 7); and
• Implementation that prioritizes collaborating and co-creating with affected sub-populations (through communities) at each step in the process (discussed in all chapters).

THE COMMITTEE AND ITS CHARGE

At the request of the National Institutes of Health, Substance Abuse and Mental Health Services Administration (SAMHSA), and Centers for Disease Control and Prevention (CDC), the National Academies of Sciences, Engineering, and Medicine convened a committee with expertise in prevention science, implementation science, health and human services research, public health research and policy, the criminal-legal system, substance use and mental health research, economics and finance, and in addressing health disparities (see Appendix A for biographical information of each committee member). The committee’s abridged Statement of Task¹ is found in Box S-1.

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¹ The complete Statement of Task is provided in Chapter 1.

THE CURRENT AND PROPOSED PREVENTION INFRASTRUCTURE FOR MEB DISORDERS

The committee identified a fragmented and unevenly developed infrastructure to deliver interventions for preventing MEB disorders. It is currently supported by government agencies at all levels (local, state, tribal, federal), academic networks for training and technical assistance, multiple national associations and research societies, and other components. And it is embedded in existing systems: behavioral health (BH),² public health, and human services agencies and organizations, along with other sectors of society from community and grassroots organizations to the education system to employers. The committee found the infrastructure currently provides more structures and supports for substance use prevention compared

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² “Behavioral health” and “mental health” are used in this report when reflecting existing agencies or organizations or referring to outcomes discussed in specific studies, while the committee uses “MEB disorders” to encompass the frequently siloed issues of “mental health/illness” and “substance use disorders.”

to mental health promotion and disorder prevention and more interventions for children, youth, and young adults than middle and older adults. It does not focus sufficiently on reducing disparities in MEB outcomes associated with social position or other socially defined circumstances—disparities that can begin early in life and increase along the life course. Nor does it focus adequately on expanding fair opportunities for everyone “to attain their full potential for health and well-being.”

Therefore, changes to approaching the evidence base and implementation, the workforce, measurement and data, governance, funding and payment, and social policy will be needed. The infrastructure can be nurtured, strengthened, coordinated, and robustly funded to close gaps and provide the interventions needed in every community and across life stages, with a focus on greater support for areas of greatest need. The infrastructure can also be built as a learning prevention framework where each component is invested in furthering ongoing processes of both doing and improving the knowledge of what works. Some characteristics of the learning health care system may apply to the infrastructure for the prevention of MEB disorders, although the focus here is more on communities and less on individuals and on systems beyond health care delivery. Applicable characteristics include data-driven learning that feeds back into the infrastructure, continuous improvement, collaboration and transparency, and seeking guidance by underrepresented groups across every component of the infrastructure.

Prevention research can be improved with more specific support for improving existing interventions and developing new ones with a focus on generalizability, external validity, and implementation science. Dedicated prevention specialists or coordinators exist in many communities, yet they are often left with limited resources to identify needs and lack the evidence-based practices to implement them. Workers in a range of settings and workforces—in schools, primary care, criminal-legal settings, community centers, in congregations, and others—may view preventing MEB disorders as ancillary or incidental to their main mission, but they are well positioned to contribute. However, billing constraints can restrict health insurance reimbursement for integrated behavioral health and primary health care services or MEB preventive care delivery in nonclinical settings. Additionally, funding for public health communication and other strategies that target the entire community is grant-dependent and not sustained.

Figure S-1 illustrates the envisioned infrastructure operating at peak capacity to support the delivery of preventive interventions. The top of the figure identifies the existing systems and infrastructures that constitute a foundation for MEB disorder prevention, while the gears reflect the major components needing support and refinement to successfully work together to deliver interventions along the life course and in a variety of settings.

To improve MEB outcomes, the infrastructure must embrace the guiding principles of promoting health equity and incorporating implementation science for the interventions and the infrastructure.

The envisioned infrastructure operates in the broader context of policies (not included in the graphic) that shape the economic, social, and environmental conditions that enhance protective factors against or create risk factors for MEB disorders.

EVIDENCE-BASED PREVENTIVE INTERVENTIONS

The committee’s charge was largely focused on the aspects of infrastructure to support the delivery of preventive programs and not a comprehensive review of programs themselves. Despite this, the committee found it useful to highlight program examples developed for different stages of the life course of particular populations or particular settings. These examples help to illustrate the flexibility required of the infrastructure to deliver such a wide breadth of programs and offers a window into future research needs related to gaps in interventions and their dissemination to communities. The evidence base is particularly targeted for children, youth, and families. These interventions positively affect many MEB health outcomes by reducing risk factors and promoting protective factors. These factors are relevant at every level of the socioecological model, that is, the intrapersonal (genetic or biological), interpersonal (family), institutional, community, and public policy. While some risk and protective factors (biological or genetic) may be fixed, many others are modifiable and can be positively influenced by preventive interventions. The evidence base for interventions for adults is not as strong, and the reach and impact of all of these interventions is limited for several reasons, including issues with generalizability and implementation. These existing prevention strategies—as critical aspects of the prevention and health promotion infrastructure—are necessary but not adequate for meeting population MEB health needs and reducing preventable poor MEB outcomes that originate during preconception and early life, and can increase along the life course.

RECOMMENDATION 2-1: The National Institutes of Health, Centers for Disease Control and Prevention, and philanthropic organizations should fund more research on the prevention of mental, emotional, and behavioral (MEB) disorders that addresses research gaps related to intervention development (to identify what works and the certainty and magnitude of outcomes) and implementation (to identify how to deliver and sustain interventions with fidelity). This research should prioritize interventions that target MEB health inequities, are needed

for different age groups, and are co-created with the populations they are intended to serve.

Funders can use existing taxonomies,³ develop new ones, pursue strategies to systematically and consistently identify research needs, and set priorities so appropriate proposals are funded and research needs are addressed. In requests for proposals, funders can emphasize the need for

• Interventions that can be tailored for different contexts, settings, and age ranges, for an array of participants from those who are easily engaged to those who have been historically excluded, underrepresented, or experienced language access barriers;
• Co-design, co-production, or co-creation of intervention and implementation approaches between investigators, community members, and/or future participants in research proposals and projects; and
• Implementation plans for interventions that prove successful.

In addition to further research needed to improve knowledge about interventions themselves, more can be done to improve the dissemination of this knowledge across communities. Dozens of clearinghouses are available in various government agencies and private organizations, but they vary in quality (inconsistent or inadequate criteria, etc.) and sustainability (fluctuating funding sources and ability to be updated with new information). The vast number of options, lack of clarity about how programs are evaluated, and how generalizable they are in any given community can be a hindrance for those wanting to implement preventive interventions. One well-known example is SAMHSA’s National Registry of Evidence-Based Programs and Practices, which evaluated interventions but was suspended in 2017 and replaced by the Evidence-Based Practices Resource Center, a static and nonevaluative database. SAMHSA is currently exploring other options in this area. An easily accessible, trustworthy, centralized repository of programs addressing MEB disorder prevention with transparent criteria, evaluations, and regular updates would greatly serve communities, coalitions, and other invested constituents.

RECOMMENDATION 2-2: The Substance Abuse and Mental Health Services Administration (SAMHSA) should manage and maintain a centralized and dynamic evidence clearinghouse for mental, emotional, and

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³ See, for example, the clinical prevention foundational issues, analytic framework, and dissemination and implementation taxonomies for identifying research gaps at https://nap.nationalacademies.org/resource/26351/ or the Reconnecting Youth Evidence Gap Map at https://reconnectingyouth.mdrc.org/egm (accessed March 10, 2025).

behavioral health that promotes standardization of criteria for inclusion and evaluation. The clearinghouse should include information about intervention effectiveness, guidance for implementation, and a focus on prevention strategies that address the needs of diverse communities.

To support uptake of effective interventions and integrate practice-based evidence, SAMHSA should also

1. Develop clearinghouse navigation tools to help implementers find relevant strategies, ensure implementation quality, and increase the likelihood of impact; and
2. Work with state and other grantees to develop a mechanism to integrate evaluation of implementation, new knowledge, and community experience.

Possible criteria for inclusion within this centralized and dynamic clearinghouse could include:

1. Quality of the evidence: reliability and internal validity;
2. Generalizability of results to specific and new subpopulations, settings, and geographic locations (external validity); and
3. Pre-implementation, implementation, and cost considerations.

Clearinghouse usability considerations include having straightforward search functions and being tailorable for different needs, concise, and jargon-free.

The Workforce for Prevention of MEB Disorders

The committee found that the MEB disorder prevention workforce is poorly characterized compared to the traditional behavioral health (BH) workforce of graduate degree–trained and licensed practitioners working largely in clinical settings. The extant prevention workforce includes workers with prevention science, public health, and related training; frontline workers from other sectors and systems (e.g., day care providers, teachers, clergy); and direct service practitioners (e.g., community health workers, community health representatives) drawn from and representative of the community. Developing and supporting an effective workforce will require review of competencies, training and certification needs, strategies for developing a pipeline and pathways to professional development, opportunities to expand and support to implement evidence-based programs (and contribute to the development of practice-based evidence) in a variety of settings, and fair pay and labor protections.

Several changes are needed to better characterize and enumerate the prevention workforce, and a SAMHSA office devoted to the MEB disorder prevention workforce could provide a point of coordination and support for all workforce matters, including better integration of prevention related to mental health and substance use.

RECOMMENDATION 3-1: In consultation with Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration should describe and enumerate the workforce for mental, emotional, and behavioral (MEB) health promotion and prevention of MEB disorders. SAMHSA should add the newly defined roles to its behavioral health workforce estimates and reports.

RECOMMENDATION 3-2: The Department of Labor should use the most up-to-date description of the prevention workforce for mental, emotional, and behavioral disorders as the basis for updates to the Standard Occupational Classifications for behavioral and public health jobs.

RECOMMENDATION 3-3: The Substance Abuse and Mental Health Services Administration should establish a Coordinating Office on the Mental, Emotional, and Behavioral Prevention Workforce or designate a lead office to coordinate prevention to delineate core competencies, develop a strategic plan, review agency programs and grants for workforce linkages, coordinate with the Centers for Disease Control and Prevention and accrediting and licensure bodies, and strengthen academic-community partnerships.

This enhanced coordination could be accomplished through collaboration between the Center for Substance Abuse Prevention and a new Center for Mental Health Promotion or a new joint Center for Prevention of Behavioral Disorders (see options supporting Recommendation 5-1). If creating a new office is not feasible, SAMHSA leaders working on behavioral health workforce issues would need to coordinate and address the various components for an effective prevention workforce.

Broader dissemination of effective strategies could be facilitated through better coordination with SAMHSA and the CDC among the departments and agencies that serve specific populations (e.g., older adults, K–12 students).

RECOMMENDATION 3-4: The Substance Abuse and Mental Health Services Administration and Centers for Disease Control and Prevention should work with the Administration for Community Living, Administration for Children and Families, U.S. Department of Education,

and Department of Justice to incorporate strategies for training on prevention of mental, emotional, and behavioral disorders for frontline personnel in those settings.

Data

Communities and their partners working to promote MEB health need several types of data: demographics, risk and protective factors (including social determinants of health [SDOH] metrics), MEB outcomes, substance use patterns and consequences, prevention resources (e.g., people, organizations, community assets), and community readiness. For population-level data, additional funding and sustained federal support for a small area local data repository is needed to help community prevention implementers integrate data from various sources and use them to plan, implement, and evaluate their efforts.

RECOMMENDATION 4-1: The Centers for Disease Control and Prevention (CDC) should sustain, enhance, and regularly update Population Level Analysis and Community Estimates (PLACES) as a data tool that communities can access for locally relevant, granular (i.e., census tract and ZIP code) data and the ability to compare themselves to peers. CDC should enhance PLACES in collaboration with the Substance Abuse and Mental Health Services Administration to add measures relevant to mental, emotional, and behavioral health and population well-being, and support functionalities to PLACES that allow community partnerships to layer their own data on PLACES data for their planning and evaluation efforts.

RECOMMENDATION 4-2: The Substance Abuse and Mental Health Services Administration, Centers for Disease Control and Prevention, and other federal agencies that provide resources for community-based prevention of behavioral disorders should include specific support for data infrastructure in all relevant grant programs, including funding for acquiring relevant data, data integrity and privacy, new data collection, data sharing, collaboration with relevant public- and private-sector partners, and obtaining training and technical assistance as needed.

Federal agencies and others have explored measures of subjective wellbeing, and the committee asserts that they can be used in tracking MEB health. A measure of population well-being would provide a more expansive way to track progress of programs and policies, complementing specific national measures, such as overdose and suicide deaths, and framing a positive high-level target for the prevention infrastructure.

RECOMMENDATION 4-3: To identify and adopt measures of population well-being that allow the nation to track progress and report on mental, emotional, and behavioral health, the Office of the Assistant Secretary of Health, National Center for Health Statistics, and the Substance Abuse and Mental Health Services Administration should convene and collaborate with relevant partners.

The measure(s) would be disaggregated by socioeconomic factors; race; and ethnicity, age, and geography.

Relevant partners may include the Health and Human Services (HHS) Office of the National Coordinator of Health Information Technology and national public health organizations, such as the Association of State and Territorial Health Officials and the National Indian Health Board.

Governance

The governance structure for prevention of MEB disorders is fragmented, with separate lines of oversight and funding for mental health and substance use disorder (SUD) and far less attention to prevention compared to reactive responses to needs for treatment and recovery. The White House has an Office of National Drug Control Policy that, though originating in the War on Drugs, has evolved to oversee a broad-based array of efforts oriented toward both treatment and prevention. But this is a SUD silo, as linkages to mental health (MH) are minimal.

SAMHSA, like the broader BH enterprise, is asymmetrical in its organizational structure, with greater attention to preventing substance use than other MEB disorders, reflected by the existence of the Centers for Substance Use Prevention and SUD Treatment compared with the singular Center for Mental Health Services, which supports treatment and prevention work with emphasis on serious mental illness.

RECOMMENDATION 5-1: To strengthen capacity and coordination to promote mental, emotional, and behavioral (MEB) health and population well-being, governance structures for prevention should be added at each level in the Executive Branch.

1. The White House could establish a central point for MEB prevention capacity and coordination. There are two options for doing this: appointing a special assistant on MEB disorder prevention to the president who serves on the Domestic Policy Council or establishing a new office on MEB prevention in the White House. Either the special assistant or the new office would coordinate with the Office of National Drug Control Policy and the Office

1. of Management and Budget and convene all executive branch departments with a role in prevention, perhaps through an interagency task force. An office would require more resources than a special assistant but could support a more robust portfolio of efforts to streamline and enhance coordination throughout the Executive Branch. There is a history of interagency task forces spearheaded or called for by an administration to help implement a strategic objective. The relevant executive branch departments include Health and Human Services (HHS), Department of Education, Department of Veterans Affairs, Department of Defense,⁴ U.S. Department of Agriculture, Department of Justice, Department of Labor, and Department of Treasury;
2. The HHS Behavioral Health Coordinating Council (or similar intra-departmental entity) could establish a workgroup on promoting MEB health and preventing MEB disorders and adopt strategies to engage individuals with lived experience; and
3. Congress could expand the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) ability to support state, tribal, and local MEB disorder prevention efforts by either establishing a Center for Prevention of Behavioral Disorders that integrates the agency’s prevention activities or by establishing a Center for Mental Health Promotion (equal to and working closely with the existing Center for Substance Abuse Prevention). In addition, the SAMHSA administrator, who is also the Assistant Secretary for Mental Health and Substance Use, should appoint a prevention advisor to support and report on state efforts to prioritize prevention.

Funding

The committee estimates that federal prevention funding for MEB disorders is approximately $4.57 billion—allocated to several HHS agencies, the Department of Education, and other federal departments and agencies. This funding is not adequate to deliver necessary preventive interventions to all communities. For example, prevention-specific parts of the budgets of SAMHSA and the Administration for Children and Families (ACF) have not kept up with inflation, and the Community Mental Health Services Block Grant has no prevention set-aside, unlike the Substance Use Prevention, Treatment, and Recovery Services Block Grant.

Descriptions of major programs often pair the words “prevention and treatment,” which suggests that prevention funding is more robust than it is.

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⁴ DoD’s prevention integration initiative is illustrative of high-level attention to prevention in domains external to HHS. https://www.prevention.mil/ (accessed October 1, 2025).

Most of the funding for behavioral health services is directed toward treatment and addressing the opioid crisis; more is needed to support primary prevention. Increasing funding for prevention could be focused on the four agencies that provide the most support for prevention of MEB disorders. More dependable funding could support implementation of evidence-based programs (EBP); help strengthen the workforce; facilitate greater access to data to inform prevention work and show improved outcomes; and nurture greater coordination and collaboration in governance and partnerships at the state and local levels. The approaches to funding could range from transformative—for example, investing holistically in MEB prevention during the impactful period from birth to 18 years of age—to narrow—such as inflation adjusting and modestly increasing capacity.

RECOMMENDATION 6-1: To secure adequate, sustainable, and locally responsive funding for the mental, emotional, and behavioral disorder prevention infrastructure, Congress should consider a range of funding options that includes:

1. Providing $14 billion in new funding to the Department of Health and Human Services for interventions on early life risk factors for mental, emotional, and behavioral (MEB) disorders for all children birth to 18 years old.
2. At a time of funding constraints, providing $1.8 billion in new funding to the Administration for Children and Families, Centers for Disease Control and Prevention, Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration would help to increase capacity for MEB disorder prevention.

Investing $14 billion across federal agencies delivering mental, emotional, and behavioral health preventive services to children and youth (up to 18 years old) would include but is not limited to the Administration for Children and Families (ACF), CDC, Health Resources and Services Administration (HRSA), and SAMHSA. Fourteen billion dollars is based on an estimate of $218 per child to provide MEB prevention services to the approximately 74 million U.S. children from birth to 18 years old. Such a commitment could ensure that all children in every community have access to the package of interventions they need to address risk factors and support positive trajectories to MEB health (e.g., reducing risk for, incidence, and severity of depression, anxiety, suicide, and substance use disorders, including alcohol use disorder, and improving general mental health and resilience along the life course as children grow up).

In a setting of fiscal constraints, a more modest $1.8 billion in new funding could be allocated to the four key federal agencies responsible for

prevention of MEB disorders, which includes adjusting for inflation for specific ACF and SAMHSA programs and expanding the capacity of specific MEB health-relevant programs in CDC and HRSA. As shown in Appendix F, this amounts to a 40 percent increase from $4.57 billion to $6.37 billion. New funding would allow greater capacity of service delivery in settings along the life course, from preconception through older adulthood.

Detailed calculations describing each of the options above are provided in Appendix F. These increases can be achieved partly by restoring the Prevention and Public Health Fund to its original amount of $2 billion to support SAMHSA and CDC prevention programs.

Medicaid reimbursement is a crucial source of funding for BH services, but barriers exist related to staffing, setting, benefits, and eligibility. Specifically, some types of workers, community settings, and population-level preventive interventions are difficult or impossible to pay with Medicaid dollars. Medicaid does not pay for population-level preventive interventions, such as public health communication campaigns. However, its amendments, authorities, flexibilities, and waivers offer opportunities for greater adaptability and experimentation. Interventions to prevent MEB disorders and promote MEB health could be supported through a range of approaches that create more sustainable, coordinated, and adequate funding beginning with greater flexibility and innovation in federal sources.

RECOMMENDATION 6-2: The committee recommends that the Centers for Medicare & Medicaid Services should

1. Encourage states to use Medicaid 1115 waivers to implement evidence-based approaches for prevention of mental, emotional, and behavioral (MEB) disorders. Potential approaches could focus on school-based strategies and the work of multisector partnerships in other community settings (e.g., accountable communities for health, faith-based, aging services) that are implementing population-based universal interventions (e.g., environmental change, media campaigns).
2. Prioritize specific quality metrics relevant to prevention of MEB disorders, e.g., screening for alcohol misuse, depression, and anxiety in all value-based purchasing programs under Medicaid and Medicare.
3. Facilitate reimbursement of non-licensed non-clinical MEB prevention workers (e.g., prevention specialists, community health workers) considered qualified to deliver such interventions.

Opportunities to generate additional resources to support the promotion of MEB health include public sector incentives and public–private

partnerships. One potential source of funding is health system community benefit resources, which most tax-exempt hospital and health systems spend in a manner that does not further their population health improvement goals and is not aligned with the spirit of providing a community benefit. Innovative mechanisms have also been tested in a variety of states and jurisdictions.

RECOMMENDATION 6-3: Congress should adopt and support the implementation of new or innovative funding mechanisms to generate sustainable and sufficient resources for promoting mental, emotional, and behavioral (MEB) health and for prevention, particularly primary, of MEB disorders by:

1. Offering incentives, such as tax credits, for large-scale social impact investing that supports universal prevention.
2. Directing the Internal Revenue Service (IRS) to provide guidance on how tax-exempt hospitals can use community benefit funding to support MEB disorder prevention in communities where behavioral disorders are priority health needs within the mandated Community Health Needs Assessment. Specifically, the IRS should modify Lines 3, 6, 7, and 8 of Part II of IRS Schedule H (Form 990) that is used to monitor community benefit spending to specifically include MEB disorder prevention.

RECOMMENDATION 6-4: State and territorial legislatures and tribal councils, respectively, should adopt and support the implementation of new or innovative funding mechanisms to generate sustainable and sufficient resources for promoting mental, emotional, and behavioral (MEB) health, and prevention, particularly primary, of MEB disorders.

Such mechanisms could include the following:

• Enact new or revise current excise taxes to earmark funding to MEB health promotion programs:
  • New potential sources of funding include sales of recreational cannabis and social media advertising taxes; and
  • Revision of alcohol excise taxes to bring them up to inflation-adjusted levels.
• Establish prevention and wellness funds, which are pools of resources raised to support community prevention efforts;
• Establish children’s cabinets and equivalent mechanisms to more effectively coordinate multiagency funding toward a shared mission; and
• Use bonds, including social impact bonds (also known as pay-for-success financing), to support MEB prevention interventions.

Too often, savings that accrue from effective implementation of MEB health interventions are not directly realized by the programs that invest in them. This fails to provide policy makers with an accurate accounting on their return on investment.

RECOMMENDATION 6-5: The Assistant Secretary for Planning and Evaluation should work with relevant experts to develop a comprehensive economic model that tests the downstream effects of investments in mental, emotional, and behavioral (MEB) disorder prevention. The model should include a range of inputs (e.g., quality early care and education), beneficiary federal agencies (e.g., Department of Health and Human Services/Centers for Medicare & Medicaid Services), and private-sector entities (employers/payers) that will reap the savings from enhancing mental, emotional, and behavioral health at a population level and eliminating MEB health disparities.

The Congressional Budget Office could refer to the model in informing the work of policy makers.

Evidence-Based Prevention Through Policy

The committee found that evidence-based social and economic policies influence trajectories toward MEB disorders, such as linkages between poverty and risk factors for poor MEB outcomes or economic stability bolstered by the Earned Income Tax Credit reducing psychological distress. New evidence on the importance of policy has been emerging in the areas of mass incarceration and exposure to firearm violence, two issues that uniquely affect U.S. children and disproportionately affect racial and ethnic minority communities.

Policies that are shown to have positive effects are not always sustained. For example, free school meals are associated with better MEB health and well-being in children and improved educational outcomes, but the pandemic-era waiver that provided free school meals for all students was ended and only a few states opted to support a continuation of it.

RECOMMENDATION 7-1: In keeping with the Foundations for Evidence-Based Policymaking Act of 2018, federal and state policy makers should use the best available evidence to sustain, restore, develop, or de-implement social and economic policies, considering the direct or indirect effects of such policies on mental, emotional, and behavioral health and population well-being.

Incarceration constitutes a risk factor for MEB disorders for both the individuals incarcerated and their families, with a detrimental impact on the

MEB health of millions of children and adults in the United States. Incarceration also catalyzes additional trajectories toward poor outcomes, such as loss of parental custody and risk of criminal activity and substance use. Research indicates that there are many opportunities to intervene before incarceration, such as civil court, drug courts, and community programming for youth, overseen by the juvenile criminal legal system. Also, efforts to reduce exposure of youth to incarceration have been shown to yield better MEB outcomes and decrease recidivism.

RECOMMENDATION 7-2: Federal, state, and county officials should enact evidence-based policies to divert from the criminal legal system and reduce reliance on incarceration where appropriate, while simultaneously building a robust community prevention infrastructure, thus enabling protective factors that support mental, emotional, and behavioral health.

Exposure to firearm violence is a major cause of MEB disorders. The 2024 U.S. Surgeon General Advisory asserted that “beyond the profound consequences of surviving a firearm-related injury, those who do not experience direct bodily harm often grapple with mental health consequences related to firearm violence exposure, including community members, children and adolescents, and families.”⁵ Firearm violence disproportionately affects youth residing in rural communities and Black youth who experience higher rates of exposure to assaults, police shootings, and community violence. Black individuals are nearly 14 times more likely to die from firearm homicide than White individuals, and their inpatient admission rates for firearm-related injuries are nine times higher. Additionally, more than 7 out of every 10 veteran deaths by suicide (already significantly higher rates than non-veterans) are by firearm. Firearm violence erodes MEB health, directly contributing to poor MEB outcomes including suicide, depression, and anxiety, especially for youth and heavily affected communities.

RECOMMENDATION 7-3: Federal, state, and local policy makers should implement evidence-based policies to prevent firearm violence—a risk factor for mental, emotional, and behavioral disorders—including but not limited to safe and secure gun storage, community violence interventions, and lethal means safety counseling.

Research undertaken or supported by different federal agencies has demonstrated the possibility of positive effects of policies on MEB health. Examples include housing vouchers and rental assistance, urban green spaces, and the Medicaid Early and Periodic Screening, Diagnostic, and

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⁵ https://www.hhs.gov/sites/default/files/firearm-violenceadvisory.pdf, p. 14 (accessed November 20, 2024).

Treatment benefit. However, MEB outcomes are not consistently included as a policy target, which represents a missed opportunity to learn whether and to what extent policies are effective at preventing MEB disorders.

RECOMMENDATION 7-4: The Department of Health and Human Services (through the National Institutes of Health, Centers for Disease Control and Prevention, and Centers for Medicare & Medicaid Services) and the relevant research entities in the Departments of Defense, Education, Housing and Urban Development, Justice, and Veterans Affairs should direct more targeted funding to research that assesses mental, emotional, and behavioral health and population well-being outcomes related to specific policies directed at social, economic, and environmental factors. Studies should include direction and strength of associations as well as an assessment of causality.

Examples for how the guiding principle of health equity and implementation science can be operationalized in the infrastructure are discussed in each chapter and include:

• Shared governance with communities and people with lived experience;
• Assurance that the evidence about programs is generalizable and represents the communities where they will be implemented and new knowledge generated feeds back into the evidence base;
• A workforce that reflects the community is culturally and linguistically competent; and
• Distribution of funding to support MEB health promotion efforts that targets the communities and subpopulations that bear the highest burden of risk factors and poor outcomes.

Implementation scientists, organizations that provide technical assistance, and others engaged in the translation of knowledge are helping to close the research-to-practice gap and inform best practices for pre-implementation, implementation, and sustainment of evidence-based interventions across settings and communities where prevention services are being delivered.

With resources and data, expertise, leadership and partnerships, and several evidence-based and promising approaches to draw on, the nation can do better in intervening across different settings and along the life course to promote MEB health and prevent MEB disorders. This report provides a blueprint for doing so.