The Suicide & Crisis Lifeline’s 988 hotline marked its one-year milestone this month. Mental health experts say the three-digit number made help more accessible than before.

[This story also ran on CBS News.]

The hotline was designed with the idea that people experiencing emotional distress are more comfortable reaching out for help from trained counselors than from police and other first responders through 911.

Since the federally mandated crisis hotline’s new number launched in July 2022, 988 has received about 4 million calls, chats, and texts, according to a KFF report — up 33% from the previous year. (The hotline previously used a 10-digit number, 800-273-8255, which remains active but is not promoted.)

At a July press event, policymakers and mental health experts celebrated the hotline’s first-year successes as well as its additional $1 billion in funding from the Biden administration. Health and Human Services Secretary Xavier Becerra described 988 as a “godsend” during taped remarks. “It may not be the solution,” he said, “but it lets you touch someone who can send you on a path to where you will get the help you need.”

Those same advocates recognized the dark reality represented by 988’s high call volume: The nation faces a mental health crisis, and there is still much work to be done.

One year in, it’s also clear that the 988 hotline, a network of more than 200 state and local call centers, faces challenges ahead, including public mistrust and confusion. It’s also clear the hotline needs federal and state funding intervention to be sustainable.

Here’s a status check on where things stand:

What Worked?

The original 1-800 national mental health crisis hotline has operated since 2005. The huge increase in calls to 988 compared with those to the 1-800 number in just a year is likely linked to the simplicity of the three-digit code, said Adrienne Breidenstine, vice president of policy and communications at Behavioral Health System in Baltimore. “People are remembering it easily,” she told KFF Health News.

According to a survey by NAMI and IPSOS conducted in June, 63% of Americans had heard of 988, and those ages 18 to 29 were most aware. Additionally, the survey found that LGBTQ+ people were twice as likely to be familiar with 988 as people who don’t identify as LGBTQ+.

The 988 hotline provides 24/7 support for people in suicidal crisis or other kinds of emotional distress, Breidenstine said. “They can be calling if they really just had a bad day,” she said. “We also get some calls from people experiencing postpartum depression.” Callers are directed to a menu of options to choose which kind of service would best help them, including a veterans’ line.

As it launched, mental health experts worried about the hotline’s ability to keep up with demand. But it appears to be growing into its position. “Despite a huge increase of demand on the system, it’s been holding up, and it’s been holding up exceptionally well,” Hannah Wesolowski, chief advocacy officer at the National Alliance on Mental Illness, told KFF Health News. It now takes an average of 35 seconds for someone reaching out to 988 — by calling or texting — to reach a counselor, according to data from the Substance Abuse and Mental Health Services Administration. A year ago, that average was one minute and 20 seconds.

Wesolowski said one of the biggest surprises with the launch was the frequency of text-message traffic. In November 2022, the Federal Communications Commission voted to require 988 to be texting-friendly.

In May, according to SAMHSA, 988 received about 71,000 texts nationwide with a 99% response rate, compared with 8,300 texts in May 2022 with an 82% response rate.

This month, HHS announced the addition of Spanish text and chat services to 988.

Challenges Ahead

More than half of Americans have heard of 988, but only a small fraction understand how the hotline operates. According to NAMI’s survey, only 17% of people who responded said they were “very/somewhat familiar” with the hotline.

Most people think that by calling 988, like 911, emergency services will automatically head their way, the survey found. Currently, 988 does not use geolocation, meaning call centers don’t automatically receive information about callers’ locations. Vibrant Emotional Health, which operates the hotline, is working to incorporate geo-routing into the system, which would help identify callers’ regions — but not exact locations — making it possible to connect them to local counseling groups and other mental health services.

But incorporating geo-routing into the hotline isn’t without controversy. When it launched, people responded on social media with warnings that calling 988 brought a heightened risk for police involvement and involuntary treatment at psychiatric hospitals. “Based on the trauma that so many people in the mental health community have long experienced when they’ve been in crisis, those assumptions are very understandable,” Wesolowski said.

Fewer than 2% of calls end up involving law enforcement, she said, and most are de-escalated over the phone.

“The vast majority of people think that an in-person response is going to happen whenever you call — and that’s just simply not true,” Wesolowski said.

Another challenge mental health advocates face is informing older adults about 988, especially veterans, who are at higher risk of having suicidal ideations. Americans ages 50 to 64 had the lowest awareness rate of 988 — at 11% — among all age groups, according to NAMI’s survey.

This is a telling sign of how older generations are less willing to discuss and admit to mental health struggles, Wesolowski said. “Young people are just more willing to be open about that, so I think that breaking down that stigma across all age groups is absolutely vital, and we have a lot of work to do in that space.”

Is 988 Sustainable?

Since the hotline launched, it has been dependent on federal grants and annual appropriations. A gush of funding flowed when 988 launched, “but those annual appropriations are something you have to keep going back for year after year, so the sustainability aspect is a little more fraught,” Wesolowski said.

This is where Congress and state legislatures come in.

Mental health leaders hope to push legislation that allows 988 to be funded the same way 911 is nationwide. The Wireless Communications and Public Safety Act of 1999 mandated 911 to be the country’s universal emergency number, and ever since, users have automatically been charged — an average of about a dollar a month — on their monthly phone bills to fund it. Six states have imposed a similar tax for 988, and two states — Delaware and Oregon — have bills for this tax on their governor’s desks.

It’s under the FCC’s power to levy a nationwide tax, but the federal agency hasn’t done so yet.

The post A Year With 988: What Worked? What Challenges Lie Ahead? appeared first on Medika Life.

As the federal government prepares to launch the national three-digit number “988” for the mental health crisis hotline next month, a new KFF analysis shows that suicide death rates increased by 12 percent in the decade from 2010 to 2020 — with death rates rising fastest among people of color, younger individuals, and people who live in rural areas.

The number of suicide deaths peaked at 48,344 in 2018 and then decreased slightly in 2019 and 2020, although some research suggests that some suicides may be misclassified as drug overdose deaths. Between 2019 and 2020, drug overdose deaths increased by 31 percent.

Suicide deaths by firearms accounted for more than half of the 45,979 suicides in 2020, the most complete data available, according to the analysis. Looked at another way, suicide deaths accounted for more than half (54%) of all deaths involving a firearm in 2020.

Among people of color, the highest increase in suicide death rates was among Black people (43% increase), followed by American Indian or Alaska Natives (41%), and Hispanic people (27%). As of 2020, American Indian and Alaska Native people had the highest suicide death rate, at 23.9 per 100,000 people – substantially higher than the rate for White people (16.8 per 100,000 people). Suicide death rates for Black, Hispanic, and Asian and Pacific Islander people were all less than half the rate for White people.

Suicide death rates also increased significantly in rural areas, rising 23 percent over the decade — possibly due to acute shortages of mental health workers in these areas. Among adolescents age 12 to 17 the suicide death rate increased 62 percent, and among young adults ages 18 to 23 the increase was 33 percent.

Suicide death rates varied substantially by state in 2020, ranging from 5.5 per 100,000 population in Washington, D.C. to a high of 30.5 per 100,000 people in Wyoming.

Against that backdrop of need, the federally mandated crisis number “988” will be available to all landline and cell phone users beginning July 16. Callers who are suicidal or experiencing a mental health crisis will be routed to the National Suicide Prevention Lifeline and connected to a crisis counselor.

For the full analysis, as well as other KFF data and analyses related to mental health, visit kff.org.

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In this article, I take a quick look at a recent review of brief interventions to prevent suicide after a person has made a visit to an emergency or urgent care service for suicidal ideation or attempted suicide or has been discharged from an inpatient stay for those reasons.

Such persons are at high risk of subsequently dying by suicide, especially if they break contact with mental health care, which they often do. Yet emergency departments are not typically equipped to provide follow up care. They depend on patients engaging with mental health care elsewhere.

The authors were interested in interventions that could be delivered in a single contact, perhaps with brief messages afterward. The interventions were intended to engage patients with mental health care and reduce the likelihood of a subsequent suicide attempt.

The article is paywalled, but if you click on the link, you can at least get a look at a detailed abstract.

Doupnik SK, et al. Association of Suicide Prevention Interventions with Subsequent Suicide Attempts, Linkage to Follow-up Care, and Depression Symptoms for Acute Care Settings: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2020;19146. doi:10.1001/jamapsychiatry.2020.1586

The authors undertook a systematic search of multiple databases for titles and abstracts in the past 20 years that included relevant key words. This search yielded almost 4000 articles, but ultimately only 14 studies were considered eligible for inclusion in the review, with outcomes for 4270 patients.

Each article included at least one of these outcomes: subsequent suicide attempts, linkage to mental care, and depression symptoms at follow-up.

Components of the interventions included brief contact in the form of telephone calls, handwritten notes, and text messages. Three studies included coordination of care, which involved back and forth communication between the clinic team referring the patient and the team receiving the patient for follow-up outpatient care. Five studies involved a Safety Planning Intervention:

(1) identifying personalized warning signs for an impending suicidal crisis, (2) determining internal coping strategies that distract from suicidal thoughts and urges, (3) identifying family, friends, and social places that can distract from suicidal thoughts and urges, (4) identifying individuals who can help provide support during a suicidal crisis, (5) listing mental health professionals and urgent care services to contact during a suicidal crisis, and (6) lethal means counseling for making the environment safer.

The review reports the pooled effects of the brief intervention were a moderate increase in engagement in mental health care. The authors estimated that these results represented a 22.5% increase in receipt of follow-up care in patients receiving the intervention over usual care.

There was a small reduction in subsequent suicide attempts, estimated to be a 3.5% reduction or 78 fewer suicide attempts in the 2241 patients receiving the intervention.

However, there was no significant reduction in depressive symptoms associated with patients receiving the intervention versus being in the control condition.

I gave a look at the figures and supplementary tables and found that the studies included in the meta-analysis were generally small, except two larger projects reported in three articles. Neither was a randomized trial, but both involved a matched comparison, either between sites receiving the intervention to similar sites providing usual care or the same sites before and after the intervention. These two projects accounted had three-quarters of the weight in the analyses of subsequent suicide attempts.

The authors did careful analyses and found that removal of any one study did not affect their results. However, removing the results of the two projects eliminated the significance of the reduction in suicide attempts associated with receiving the intervention.

I took a further look at the large project that provided the two effect sizes. It was an impressive study of patients receiving the Safety Planning Intervention (SPI+) after being recruited from the emergency departments of US Veterans Health Administration hospitals. Results from the larger component of the study were:

The SPI+ was associated with about 50% fewer suicidal behaviors over a 6-month follow-up and more than double the odds of engaging in outpatient behavioral health care.

Veterans have about a fifth higher risk of suicide than the general population, but the VA hospitals have better coordination of care than other parts of the thoroughly fragmented American health care system.

Lower-income patients receiving Medicare have more coordinated care in the public health system and fewer worries about insurance coverage. However, persons receiving insurance through their employers may face copayments and those who are unemployed may lack insurance coverage altogether.

Bottom line is that SPI+ intervention may be less effective in the mostly less organized aspects of American health care.

The authors of the review stated

“We were not able to examine whether brief suicide interventions ultimately reduced suicide deaths because most studies in the review did not include death as an outcome.”

But isn’t reducing deaths the purpose of suicide prevention? I doubt a meta-analysis with a pool of only 4270 patients is large enough to register a significant effect on deaths, even in a very high-risk group recruited from EDs and discharges from inpatient stays. At that level of risk, most patients will still not die by suicide, regardless of whether they get an intervention.

I have been an external scientific advisor for two decades of multi-region, multilevel community-based programs in Europe and a significant decrease in deaths has eluded us. Even when these projects relied on a composite outcome of deaths plus serious efforts at self-harm, we have mostly just missed an effect, pooling outcomes from five countries or more.

I was delighted to discover a few years ago the first study demonstrating a significant reduction in deaths among teens at high risk of suicide.

The intervention involved assigned them an adult buddy to give them support and keep them in treatment after they were discharged from an inpatient stay. The study only achieved a modest effect when the teens were followed up to 11 years.

The study actually found no significant decrease in suicide. Only when the investigators combined deaths due to suicide with deaths due to substance and alcohol use but judged not to be intentional self-harm. Apparently, teens at high risk of suicide as often die from using drugs and alcohol as from a deliberate attempt to end their lives.

Like the current review, this study was only a signal, not a definitive conclusion about how we can prevent deaths by suicide.

Every death by suicide, every effort at serious self-harm is a tragedy and a loss, not only for a person but for a circle of people for whom that person’s life has meaning.

Looking back, family members and professionals can usually identify some point where something could have been done differently that might have saved a life. But predicting the past does not allow us to predict the future and precisely when and where the next suicide will occur and what could be done to prevent it.

Every suicide is a tragedy, but it is inevitable that somewhere the next suicide will occur. Believing otherwise only leads to the needless blame of family members and punishing professionals who only in hindsight can identify what could have been done.

Suicide is infrequent enough and has such diverse causes that no single risk factor or combination will predict accurately what specific individual will die by suicide. Most individuals who die by suicide were not at high risk. Preventing suicide is complicated.

I sometimes advise members of the Canadian government on how to spend scarce resources wisely in efforts to deal with suicide as a major public health issue. I recently reminded them of what they were up against.

In 2017, the last year for which full data are available, there were 4157 suicides in Canada. The Canadian population in 2017 was 36.5 million, but this population is spread across 3.85 million mi.² 72% of the population is concentrated within 150 km (93 miles) of the nation’s southern border with the United States, but that is one of the longest borders the world. Additionally, there is great diversity within the Canadian population and that diversity matters when suicide prevention is being considered.

What then is to be done? We know that restriction of the means to prevent suicide is an evidence-based strategy that will ultimately reduce death by suicide on a population basis.

We know how ready access to affordable primary care and specialty mental health care reduces a risk factor for suicide and has its own benefits beyond reducing suicide. How this is achieved will differ with different populations in different contexts.

The current well-done review with its conservative analyses and interpretations has some modest but important messages. Brief interventions may well be able to keep high-risk persons in contact with mental health services and just may reduce acts of intentional self-harm. Those are excellent goals in themselves.

Special thanks to Dr. Stephanie Doupnick for her answers to my questions about her team’s review.

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