Iread with great interest the discussion by Ramchand et al. of the Deepwater Horizon oil spill’s impact on US Gulf Coast residents.^{Reference Ramchand, Seelam and Parks1} The authors should be commended for an interesting study that highlights the importance of considering behavioral health in disaster mitigation, preparedness, response, and recovery. I offer the following comments and observations.

The authors report that, even though 47% of adults surveyed appeared to be in need of services for alcohol use disorder, depression, or anxiety, “only 19% had seen a mental health care provider in the past 12 months” (p. 4). This is sadly not inconsistent with national-level data, such as that from the National Survey on Drug Use and Health (NSDUH), regarding persons with a “perceived unmet need” for mental health and substance use disorder treatment. Cost continues to represent a major barrier to accessing behavioral health services.² The impact of stigma (eg, concerns about negative opinions from one’s neighbors/community or employer), concerns about insurance payment and scope of coverage, and persons not knowing where to go for services also are notable barriers to care for mental health at a national level. Such challenges may explain in part why some of those impacted by recent disasters in the Gulf Coast are not seeking needed care. The authors’ findings reemphasize the need for a strong national commitment to parity such that access to services and quality of care for behavioral health conditions is no less than that expected for physical health conditions. ³ As well, emergency planners should be aware of such resources as https://findtreatment.samhsa.gov/locator that may help identify behavioral health providers and link those in need to available services.

The authors also note in their discussion the impact of potential resource loss and financial security. This is an important national issue of growing concern to the Federal Emergency Management Agency (FEMA) and community advocates. Reports that up to 40% of Americans would have difficulty covering an unexpected $400 expense underscore the challenges many people face even without the additional challenges imposed by a disaster or emergency. ⁴ Recognizing that everyone has a role to play, consistent with their life circumstances, FEMA has emphasized resilience and supports a Whole Community approach (https://www.fema.gov/whole-community).

While the general information provided by the authors as to health coverage and usual source of care is interesting, it would be helpful as well to know more about the specific sources of health insurance coverage held by the study population (eg, Medicare, Medicaid, Marketplace, Private/self/employer-based)? Access to behavioral health services and the scope of benefits offered may vary among these types of health coverage. It would also be interesting to evaluate whether those surveyed “churned” between different sources of coverage in the weeks and months following the disaster and whether this disrupted their care? (Churning occurs when individuals lose their existing insurance coverage entirely or transition from 1 form of health coverage to another, such as Medicaid to Medicare or private insurance). ^{Reference Roberts and Pollack5}

Lastly, the authors also point to the value of state-level data for emergency planning. Substance Abuse and Mental Health Services Administration (SAMHSA) has published state level resources that may be of interest. ⁶ Other resources with data at the state and local level also may be useful (eg, https://www.countyhealthrankings.org/; https://ce.naco.org/; https://www.cdc.gov/features/500-cities-project/index.html; http://statehealthcompare.shadac.org/).