New 988 Suicide Hotline: Hope or Hype?

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The National Suicide Prevention Lifeline is getting an upgrade. On July 16, 2022, the Lifeline will change from its previous number (800-273-8255) to just 3 digits: 988. Although the old number will remain available for calls, individuals may call, text, or chat 988, where they will be connected with trained counselors.¹

Additionally, if functioning as intended, operators will be able to counsel callers 24 hours a day and dispatch specially trained responders, hopefully reducing armed law enforcement interventions and emergency department (ED) visits.

“Having a 3-digit number sends the message that mental health emergencies are as important and require the same level of response as other types of health emergencies, and it makes it easier for clinicians to counsel their patients on how to access emergency mental health care,” Margie Balfour, MD, PhD, chief of quality and clinical innovation at Connections Health Solutions and associate professor of psychiatry at the University of Arizona, told Psychiatric Times™.

Currently, when individuals call the Lifeline, they hear a greeting and then a list of options: “Press 1 to connect to the Veterans Crisis Line” and “Press 2 (“Oprima dos”) for the Spanish subnetwork.” Callers who do not choose either of these options are routed to a local Lifeline crisis center based on their area code. If the local center is unable to take their call, they are rerouted to another center within the network.²

The Lifeline’s network has more than 200 crisis centers in place. From its inception in 2005 through 2020, the Lifeline has received 20,478,698 calls.³ After the past few years of crisis, 988’s introduction may prove an opportunity for restructuring mental health emergency response beyond suicide.

“Far more than just a rebrand of the National Suicide Prevention Lifeline, the implementation of 988 provides an opportunity to reform and improve our nation’s crisis response system,” Christine Yu Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention, told Psychiatric Times™. She added that 988 “is an opportunity to reimagine crisis response and increase the involvement of trained mental health professionals who are equipped to address the needs of a person in crisis.”

Easier Number, More Calls

Right now, the lifeline receives approximately 4 million calls or texts per year. In 2020, of more than 940,000 total callers, 22.57% had suicidal thoughts within the past 24 hours, 4.03% were believed to be at imminent risk of suicide, and 0.90% were in the midst of a suicide attempt during the call.⁴ About 24.60% of callers required emergency services to be dispatched to their location.⁵ All these calls, in addition to calls from local crisis centers and certain 911 calls, will be redirected to 988.

Use of the Lifeline is expected to grow exponentially in coming years, potentially attracting more than 10 million individuals, according to some estimates.⁶ By 2026, volume could reach up to 24 million callers or texters per year.² This has led to increasing questions and concerns over whether the hotline will be able to meet the already vast demand. According to New York Times data analysts, approximately 17% of the 2 million calls in 2021 were abandoned before the caller could receive help.⁶ This may be a result of long hold times and limited staffing in call centers.⁶

Among many goals, 988 hopes to answer 95% of all incoming calls within 20 seconds.⁶ “The infrastructure of local crisis call centers must be strengthened to address the needs of millions of people in distress every year. Building capacity at the state level is critical so calls do not go unanswered, wait times do not increase, and people get the help they desperately need. These centers must be adequately staffed to respond to the projected increase in call volume and ensure training is provided for crisis center staff and volunteers,” Moutier shared with Psychiatric Times™.

Infrastructure and Logistics

Since the Lifeline’s launch, the national network and the network administrator have been funded through the Substance Abuse and Mental Health Services Administration (SAMHSA), whereas local Lifeline crisis centers have received funding through varied federal, state, local, and private sources. SAMHSA has significantly increased federal funding resources for the national network and local crisis call centers to help ensure a smooth transition to 988.⁴ The current crisis system has been historically underfunded and undervalued, but new funding developments may help meet the growing need.

“If we are going to do this, then we must fund mental health at the level we fund law enforcement and paramedics. There is a massive discrepancy—multitudes of salaries’ discrepancy—there. We must pay people to be on call 24/7. It is going to take a pretty significant financial dedication,” Tony Thrasher, DO, DFAPA, president of the American Association for Emergency Psychiatry and medical director of crisis services in the Milwaukee County Behavioral Health Division in Wisconsin, told Psychiatric Times™.

In 2022, planned federal funding is $282 million. Of that, $177 million will go toward strengthening network operations including expanding paid and trained staffing for backup, specialized services, and chat and text centers; building up data and telephony infrastructure; strengthening standards, training, and quality improvement; and ensuring evaluation and oversight. The remaining $105 million will go to local crisis centers for expanding capacity to increase response rates, providing follow-up so individuals are effectively engaged with local behavioral health crisis services, staff are sufficiently paid, and staff/volunteers are adequately trained to provide evidence-based interventions even in high-risk populations.⁴

Nonprofit Lifeline administrator Vibrant Emotional Health is also providing funding through grants to 49 states and US territories through the Lifeline’s 988 State Planning Grant Initiative. The funds will be used to develop coordination, capacity, and communications surrounding the launch of 988.⁷

The National Suicide Hotline Designation Act (S.2661) allows states to collect revenue to sustain and expand local crisis services. Fees will be collected on both land and cell phone bills to provide ongoing financial support for crisis call centers. The Biden administration recently announced it will allot an additional $700 million to local crisis centers in its fiscal year 2023 budget, but each state will need to maintain its sustainable revenue stream and infrastructure for 988. States that fail to do so face increased risk of individuals in crisis not getting the support they need.

Despite this increased funding, as of May 2022, at least 13 states—Alabama, Colorado, Idaho, Indiana, Kentucky, Minnesota, Nebraska, Nevada, New York, Oregon, Texas, Virginia, and Washington—have passed 988 implementation laws that include fee measures to pay for the expected increase in calls.⁸ At least 11 states—California, Florida, Idaho, Kansas, Massachusetts, Michigan, New Jersey, New York, Ohio, Vermont, and Washington—have introduced new or additional legislation.⁹ Without significant supplemental state funding and staffing, the Lifeline may have difficulties delivering on goals. The focus will be on these states to iron out the details of how 988 will function in practice.

“Like any big undertaking, the devil is in the details—and 988 is a huge undertaking. You are taking a network of 200 or so suicide hotlines and trying to create a uniform system, which is hard enough,” said Balfour. “Opening up access without a crisis system in place could potentially make problems like ED boarding worse. We need to build that crisis system of care, and that will take time. There is legislation in Congress to start laying the foundation for that—creation of national standards, funding for planning and infrastructure, and parity coverage by health insurance. Although 988 has the potential to catalyze a huge transformation of crisis services, that will be a stepwise process that will happen over years.”

Thrasher agrees. “You are asking mental health to be fire, [emergency medical services (EMS)], and law enforcement. Mental health can be like that, but then you have to fund and staff it appropriately.”

Despite these concerns, the conversion to 988 is “not optional,” according to SAMHSA.⁸ To increase staffing, SAMHSA has put out a call online, encouraging individuals to apply: “These centers are looking to bring on new volunteers and paid employees. You will receive training, so if you are a caring person who wants to help those in crisis, apply today.”¹⁰

Lessons From 911

To best gauge how the rollout of 988 may proceed, it might be time to look to the past, specifically to 911. The first 911 call was made in February 1968.¹¹ The National Academy of Sciences had published a report emphasizing the epidemic rates of accidental deaths and injuries in 1966.¹² The report suggested the need for a single, nationwide telephone number to call for assistance.

It took almost 20 years to create the National 911 Program. Established in 2004, the program supports state efforts to improve 911 services by creating resources and disseminating grant funding for 911 technology and operations. If that is any indication, it could take 20 years before the 988 program is fully functional.

Even now, 911 is not a perfect system. According to a 2002 study of 911 response times, mortality rates in medical emergencies rose if response time increased beyond 5 minutes.¹³ For dispatchers, dealing with traumatic or verbally abusive calls is correlated with lower organizational commitment, a higher desire to leave the job, and greater emotional exhaustion.¹⁴ Trauma exposure also affects ambulance operatives, with some reporting angry outbursts, trouble sleeping, nightmares, flashbacks, and increased alcohol consumption.^15,16

Training initiatives for 988 dispatchers may need to keep this in mind. According to SAMHSA, current training is primarily determined by each individual crisis center based on its organizational needs. However, the Lifeline Core Clinical Training is in development, and will consist of self-paced online courses covering essential skills for crisis counselors who answer calls/chats/texts within the Lifeline network. Further training to address the specific needs of populations at higher risk of suicide is also in development.¹⁷

Working Toward Decriminalization

Approximately 1 in 10 individuals with mental health disorders have interactions with law enforcement prior to receiving psychiatric care,¹⁸ and up to 10% of police calls are for mental health emergencies.¹⁹ Individuals with serious mental illness account for 17% of use-of-force cases and 20.2% of suspects injured in police interaction.²⁰ Furthermore, injury, death, and other adverse outcomes are 10.7 times more likely for individuals with mental health disorders.²⁰ Negative outcomes are also disproportionately experienced by people of color.²¹ The 988 hotline will provide an option beyond 911 for patients, caregivers, and witnesses to call during a mental health emergency.

According to a 2022 poll commissioned by The Trevor Project, 36% of adults do not trust police officers to be the first responders in a mental health crisis. In contrast, at least 7 in 10 adults trust social workers, psychologists, and EMS.²²

“A law enforcement response to mental health crises only perpetuates the myth and association some people may have between mental illness and criminality,” Moutier shared with Psychiatric Times™. However, the elimination of law enforcement from mental health crisis response may not be plausible, particularly if there are firearms involved. Thus, Thrasher suggested a combined model of mental health team and police: “If we get called for a suicidal individual who is at home with a gun, I won’t let my team go in there—it’s a safety concern. We have to have law enforcement or some ability to safely clear and handle people that are using firearms before we can speak to them.”

Will It Impact Outcomes and Care?

According to a national poll, 46% of adults have never heard of 988.²² With nearly half of adults unfamiliar with 988, will this resource help clinicians and their patients? Psychiatric Times™ conducted a poll, asking 2 questions:

-Will 988 help reduce suicide?

-Do you think this will impact your practice?

Approximately 63% of respondents said they believed the implementation of 988 will reduce suicide.²³ However, on affecting practice, respondents were not totally convinced, with a 50/50 split. What are your thoughts on 988? We would love to hear: PTEditor@MMHGroup.com.

To see the Psychiatric Times™ Editor in Chief's thoughts on 988, see "New 988 Suicide Hotline: Thoughts From the Editor in Chief."

References

1. The lifeline and 988. National Suicide Prevention Lifeline. Accessed April 12, 2022. https://suicidepreventionlifeline.org/current-events/the-lifeline-and-988/

2. 988 serviceable populations and contact volume projections. Vibrant Emotional Health. December 2020. Accessed April 12, 2022. https://www.vibrant.org/wp-content/uploads/2020/12/Vibrant-988-Projections-Report.pdf

3. Suicide prevention by the numbers. National Suicide Prevention Lifeline. Accessed April 12, 2022. https://suicidepreventionlifeline.org/by-the-numbers/

4. Substance Abuse and Mental Health Administration. 988 appropriations report. December 2021. Accessed May 11, 2022. https://www.samhsa.gov/sites/default/files/988-appropriations-report.pdf

5. Gould MS, Lake AM, Munfakh JL, et al. Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: evaluation of caller risk profiles and interventions implemented. Suicide Life Threat Behav. 2016;46(2):172-190.

6. Eder S. As a crisis hotline grows, so do fears it won’t be ready. The New York Times. March 13, 2022. Accessed April 5, 2022. https://www.nytimes.com/2022/03/13/us/suicide-hotline-mental-health-988.html?referringSource=articleShare

7. Vibrant Emotional Health to provide state grants in preparation for future 988 dialing code for the National Suicide Prevention Lifeline. News release. Vibrant Emotional Health. January 25, 2021. Accessed May 11, 2022. https://www.vibrant.org/wp-content/uploads/2021/01/Vibrant-988-Planning-Grant-Announcement.pdf?_ga=2.13525815.1606522482.1652114257-409111235.1652114257

8. Howard J. States prepare for summer launch of new 988 suicide prevention number. CNN. May 6, 2022. Accessed May 16, 2022. https://www.cnn.com/2022/05/06/health/988-suicide-prevention-number-states-prepare/index.html

9. State legislation to fund and implement ‘988’ for the National Suicide Prevention Lifeline. National Academy for State Health Policy. January 18, 2022. Accessed April 27, 2022. https://www.nashp.org/state-legislation-to-fund-and-implement-988-for-the-national-suicide-prevention-lifeline/

10. 988 suicide and crisis lifeline volunteer and job opportunities. Substance Abuse and Mental Health Administration. Updated May 12, 2022. Accessed May 16, 2022. https://www.samhsa.gov/find-help/988/jobs

11. The National 911 Program celebrates 50 years of 911. 911.gov. Accessed April 27, 2022. https://www.911.gov/50-years-of-911.html

12. Committee on Trauma and Committee on Shock; Division of Medical Sciences; National Academy of Sciences; National Research Council. Accidental death and disability: the neglected disease of modern society. September 1966. Accessed April 27, 2022. https://www.ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf

13. Blackwell TH, Kaufman JS. Response time effectiveness: comparison of response time and survival in an urban emergency medical services system. Acad Emerg Med. 2002;9(4):288-295.

14. Sprigg CA, Armitage CJ, Hollis K. Verbal abuse in the National Health Service: impressions of the prevalence, perceived reasons for and relationships with staff psychological well-being. Emerg Med J. 2007;24(4):281-282.

15. Gallagher S, McGilloway S. Living in critical times: the impact of critical incidents on frontline ambulance personnel—a qualitative perspective. Int J Emerg Ment Health. 2007;9(3):215-223.

16. Adams K, Shakespeare-Finch J, Armstrong D. An interpretative phenomenological analysis of stress and well-being in emergency medical dispatchers. J Loss Trauma. 2015;20(5).

17. 988 frequently asked questions. Substance Abuse and Mental Health Administration. Updated April 22, 2022. Accessed May 16, 2022. https://www.samhsa.gov/find-help/988/faqs

18. Livingston JD. Contact between police and people with mental disorders: a review of rates. Psychiatr Serv. 2016;67(8):850-857.

19. Todd TL, Chauhan P. Seattle Police Department and mental health crises: arrest, emergency detention, and referral to services. J Crim Justice. 2021;72:101718.

20. Laniyonu A, Goff PA. Measuring disparities in police use of force and injury among persons with serious mental illness. BMC Psychiatry. 2021;21(1):500.

21. Chow JCC, Jaffee K, Snowden L. Racial/ethnic disparities in the use of mental health services in poverty areas. Am J Public Health. 2003;93(5):792-797.

22. Morning Consult. U.S. adults’ knowledge on suicide prevention and 988. The Trevor Project. April 2022. Accessed May 16, 2022. https://www.thetrevorproject.org/wp-content/uploads/2022/04/988-poll-report.pdf

23. Poll: what are your thoughts on 988? Psychiatric Times. April 7, 2022. https://www.psychiatrictimes.com/view/poll-what-are-your-thoughts-on-988 ❒