Addressing Suicide and Other Mental Health Crises With 988

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Q&A

According to the US Centers for Disease Control and Prevention (CDC), suicide rates reached an all-time high in 2022.¹ Psychiatric Times® sat down with Margie Balfour, MD, PhD, of Connections Health Solutions to discuss the 988 Suicide & Crisis Lifeline, its importance in addressing mental health crises, and how hospitals and health care facilities can get involved.

Psychiatric Times: Given the alarming increase in suicide rates, 988 has gained significant attention. Can you elaborate on the importance of the 988 initiative and how it can contribute to addressing the current mental health crisis?

Margie Balfour, MD, PhD: 988 is a critical piece of our nation’s suicide prevention efforts. 988’s predecessor is the National Suicide Prevention Lifeline—a network of over 200 call centers across the United States that was linked by a common 1-800 number since 2006—and the research on Lifeline call centers shows that callers have reduced thoughts of suicide and feelings of hopelessness after calling.² 988 expands access to this important intervention by linking it to an easy-to-remember, 3-digit number and creating the ability for the public to access it via text and chat.

Compared to a year ago, the number of people contacting the Lifeline via text increased nearly tenfold.³ Furthermore, the implementation of 988 has catalyzed an expansion of crisis services overall with increased funding for mobile crisis teams and crisis stabilization facilities.⁴ The bottom line is that more people have easier access to these life-saving services, and access will continue to increase as these new services grow.

PT: A recent National Alliance on Mental Illness (NAMI) poll1 indicates strong public support for federal funding in mental health care, particularly for 988. How can this widespread support translate into meaningful changes in mental health policy and funding priorities? What specific actions or strategies do you believe can help policymakers address the urgent needs outlined in the poll?

MB: The broad public and bipartisan support for crisis care is remarkable and creates an opportunity for a once-in-a-generation expansion of crisis services.⁴ We are in a similar position as the emergency medical services field was in the 1970 to ‘80s following the first 911 call in 1968, and now we cannot imagine life without ambulances, emergency rooms (ERs), etc. States across the nation are building the comparable services for behavioral health emergencies—mobile crisis teams, crisis stabilization facilities, etc.

However, thus far most of this work is being financed by Substance Abuse and Mental Health Services Administration (SAMHSA) funds, Medicaid, and other state and local funds, and there are significant disparities in insurance coverage for behavioral health versus medical emergencies.⁵ More than 220 million Americans with Medicare or private insurance do not have coverage for mobile crisis or crisis stabilization facilities. Ambulances cannot get paid for taking people to a crisis center instead of emergency rooms.

These services need parity coverage. We also need to develop clear definitions and standards to describe different types of crisis stabilization facilities,⁶ similar to how emergency medical systems have trauma center classification (Level 1, Level 2, etc) so that communities can plan crisis systems that can take care of everyone in need.

PT: How do you foresee advancements in mental health research contributing to suicide prevention and improved services? Are there specific areas of research or innovation that you find particularly promising in addressing the complex challenges associated with mental health and suicide prevention?

MB: I think peer support from people who have lived experience with suicidal thoughts and other behavioral health challenges can be enormously helpful, and there is increasing interest in research to help us better understand how it is helpful, in what situations, for which populations, etc. We also need research to better understand, from a systems perspective, how different crisis services affect outcomes and cost so we can be sure we are building and funding the systems communities need.

PT: How are hospitals and health care facilities preparing for the implementation of 988? What challenges and opportunities do you foresee in this transition, and how can health care organizations collaborate to ensure a seamless and effective response to mental health crises?

MB: Hospitals can start right now by incorporating 988 and local crisis resources into their discharge planning. Instead of sending patients out of the ER with instructions to call 911 if they have a future crisis, tell them to call 988. If they do have to call 911, educate them on how to ask for an officer with mental health training. Learn about local community resources. Is there a mobile crisis team? Is there a crisis stabilization center they can go to besides the ER?

They can also get involved in planning the future crisis system. Every state received planning grants as part of the 988 implementation, and pretty much every community has some kind of group working on this. This is a great opportunity for hospitals to look at what happens to patients with behavioral health emergencies in their system.

What happens in the outpatient primary care clinic if someone is suicidal? Instead of calling 911/police, can you work out an arrangement to call 988 or have a mobile crisis team come instead? Some hospitals are building crisis stabilization units attached to their ER or supporting community initiatives to build a freestanding facility.

The Roadmap to the Ideal Crisis System report⁷ has more suggestions on how to get involved in community crisis collaboratives.

Dr Balfour is the chief of quality and clinical innovation at Connections Health Solutions and an associate professor of psychiatry at the University of Arizona. She is a coauthor of the report Roadmap to the Ideal Crisis System: Essential Elements, Measurable Standards and Best Practices for Behavioral Health Crisis Response.

References

1. Curtin SC, Garnett MF, Ahmad FB. Provisional estimates of suicide by demographic characteristics: United States, 2022. US Centers for Disease Control and Prevention. November 2023. Accessed January 18, 2024. https://www.cdc.gov/nchs/data/vsrr/vsrr034.pdf

2. Research and evaluation. 988 Suicide & Crisis Lifeline. Accessed January 18, 2024. https://988lifeline.org/research-and-evaluation/

3. Saunders H. Taking a look at 988 Suicide & Crisis Lifeline implementation one year after launch. KFF. July 14. 2023. Accessed January 18, 2024. https://www.kff.org/mental-health/issue-brief/taking-a-look-at-988-suicide-crisis-lifeline-implementation-one-year-after-launch/

4. Balfour M. Behavioral health crisis care’s carpe diem moment. Psychiatric Times. June 15, 2022. Accessed January 18, 2024. https://www.psychiatrictimes.com/view/behavioral-health-crisis-care-s-carpe-diem-moment

5. Kuntz L, Santarsiero C. The whole continuum of behavioral health care: reintroduction of the 988 Implementation Act. Psychiatric Times. August 21, 2023. Accessed January 18, 2024. https://www.psychiatrictimes.com/view/the-whole-continuum-of-behavioral-health-care-reintroduction-of-the-988-implementation-act

6. Balfour M. An imperfect guide to crisis stabilization units: matching the right level of care to individual needs. Psychiatric Times. May 5, 2023. Accessed January 18, 2024. https://www.psychiatrictimes.com/view/an-imperfect-guide-to-crisis-stabilization-units-matching-the-right-level-of-care-to-individual-needs

7. Roadmap to the Ideal Crisis System. National Council for Mental Wellbeing. March 27, 2021. Accessed January 18, 2024. https://www.thenationalcouncil.org/resources/roadmap-to-the-ideal-crisis-system/