The launch this month of a national three-digit mental health emergency call number is being viewed by many as a major step toward expanding access to mental health support at a time when concern remains high about the long-term psychological and emotional effects of the COVID-19 pandemic.
Starting Saturday, the National Suicide Prevention Lifeline – funded through the Substance Abuse and Mental Health Services Administration and administered by the nonprofit Vibrant Emotional Health – is scheduled to expand and receive calls or texts sent to the new three-digit, 988 emergency number, along with fielding calls and messages to its prior hotline at 1-800-273-8255.
The goal: To give people easier access to appropriate crisis counseling and referrals to resources and supports, as well as visits from a mobile intervention team in areas where those services are available. Some experts say the new 988 number marks the first substantial move in years in the effort to create a continuum of care for those suffering a mental health crisis.
Shawn Coughlin, president and CEO of the National Association for Behavioral Healthcare, acknowledges the initial process to improve the nation’s mental health crisis response system will be one of fits and starts. The hope, he says, is that the move to 988 will bolster the delivery of mental health care services over time by helping state and local governments pinpoint gaps in their systems.
“The idea is that this should really help us to identify those areas where the systems are lacking and where we need to improve,” Coughlin says.
But while 988 is slated to be a universal emergency number – and has been mandated by the federal government – the challenges of building the infrastructure to help those who call fall heavily on individual states. An initial concern involves simply raising awareness: Results of an online survey of more than 2,000 people conducted in May for the National Alliance on Mental Illness found 77% of respondents reported they had never heard of the 988 number – a figure virtually unchanged from results in October.
“We can’t take years – these things need to be figured out pretty quickly,” says Robert Gebbia, CEO of the American Foundation for Suicide Prevention.
Gebbia says raising awareness about 988 will be crucial in determining how quickly it becomes the default for mental health crisis response rather than the 911 emergency system. But he feels since many calls to 988 will be handled by counselors over the phone and not require an in-person response like 911, it may make implementation of the new system a little easier.
“When individuals start talking to a counselor, that should be their gateway into the mental health care system. Those services can start to be delivered right then and there,” Gebbia says.
Colleen Carr, director of the National Action Alliance for Suicide Prevention, said on a recent press call that her organization recently teamed up with a number of partners to create a framework for a messaging campaign that aims to help stakeholders raise awareness about 988 while ensuring outreach is aligned with the availability of local resources.
“We know crisis services look different depending on where you live,” Carr said. “So, it’s really important that our messaging is built on an aligned framework as we talk to the public about 988.”
Under the existing system, calls to the National Suicide Prevention Lifeline are answered by a mix of volunteers and paid mental health professionals working in one of more than 180 crisis call centers across the country. According to a December report from the Substance Abuse and Mental Health Services Administration, the Lifeline received approximately 3.3 million contacts in 2020 from a combination of phone calls, text messages and online chats.
Estimates within the report indicate the volume of encounters with 988 – including those routed to a related Veterans Crisis Line – could reach between 6 million to 12 million after the first year of implementation, climbing to between 13 million and 41 million by year five. Notably, as the COVID-19 pandemic wore on, the share of adults with recent symptoms of anxiety or a depressive disorder reportedly increased from 36.4% to 41.5% between August 2020 and February 2021, according to an analysis by the Centers for Disease Control and Prevention.
Miriam Delphin-Rittmon, assistant secretary for mental health and substance abuse in the Department of Health and Human Services and the leader of SAMHSA, said on a recent press call that the Biden administration has invested a total of $432 million toward the transition to 988, including $177 million dedicated to strengthening and expanding existing Lifeline network operations and infrastructure, $105 million to help local crisis call centers, and an additional $150 million as part of the Bipartisan Safer Communities Act, approved by Congress in June.
Yet states are responsible for much of the system’s capacity and stability, and there’s been varied progress on efforts to build the infrastructure needed to meet the pending demand.
“At the end of the day, states are responsible for most of the funding and implementation,” Coughlin says. “And there’s increasing evidence not all states are at the same level or as deeply engaged as other states.”
Megghun Redmon, business manager for Suicide Prevention Services of America – which operates a crisis call center in the Chicago area – says transitioning to 988 has meant trying to staff more paid workers to make up for a dearth in volunteers. But she says delays in getting funding from the state have made it difficult to recruit and hire the amount of staff needed to operate the call center 24 hours a day.
“They’ve been very slow in disseminating the money, so the funding is not there to hire the people,” Redmon says. “So it’s kind of this domino effect.”
Gebbia says he is encouraged by President Joe Biden’s proposed fiscal year 2023 budget, which calls for $697 million for “the 988 and Behavioral Health Services program.”
But other, more sustainable funding sources will need to be found on the state level to ensure call centers have the resources they need. Among the more popular proposals has been for states to levy new telecommunication fees to help pay for the 988 system, similar to how 911 systems receive funding in many states.
“States are going to have to do their part,” Gebbia says. “We think telecom fees are the way to go.”
Data helps detail the need: From April through June of this year, just six states and the District of Columbia had at least 90% of National Suicide Prevention Lifeline calls answered within their borders, compared with 10 states where less than 66% of calls were answered from within the state. According to the Lifeline, callers who aren’t answered by a call center within their state are routed to a national backup center, and those rerouted outside their state can face longer waits and are more likely to abandon a call before they’ve received help.
A recent Wall Street Journal report also found that from 2016 to 2021, 1 in 6 calls to the National Suicide Prevention Lifeline ended before a caller talked to a counselor. Hannah Collins, director of marketing and communications for the 988 Lifeline and Vibrant Emotional Health, says the abandoned call rate was approximately 17% in 2021, but explains that figure includes people who chose to disconnect themselves before connection with another person. She says 80% of callers that abandon do so after waiting two minutes or less after the greeting, and that among those calls, 28% in 2021 called back within 24 hours and were connected to a counselor.
Gebbia says having access to some type of support during a mental health crisis can play a vital role in reducing the risk of suicide. He estimates half of those who die by suicide are not receiving any type of mental health care at the time of their death.
“That’s a very lethal gap,” Gebbia says. “When someone has the courage to reach out and ask for help, we must ensure that they get it.”
Advocates say one of the long-term goals around the new 988 system is to provide responses that avoid the involvement of law enforcement. A 2015 report from the nonprofit Treatment Advocacy Center states that an estimated 1 in 4 fatal police encounters involve a person with serious mental illness.
Hannah Wesolowski, chief advocacy officer for the National Alliance on Mental Illness, says it’s estimated that anywhere from 80% to 98% of calls to 988 can be resolved over the phone, which in turn should reduce the need for an in-person response to a mental health crisis that has often been handled by police. But she says alternatives that avoid potentially criminalizing someone in the midst of a mental health crisis still are needed to support the remaining 2% to 20% of calls where in-person interventions are warranted.
“When that in-person response is needed, having mobile crisis teams that are comprised of behavioral health care professionals who are dispatched to the scene is going to provide a much more effective outcome than relying on law enforcement for a job they did not sign up for and are not equipped to handle,” she says.
Mobile crisis teams are available in some states, like Georgia, to respond to mental health emergencies. Wesolowski says states also should invest in creating crisis stabilization facilities that can provide short-term assistance and connect people to longer-term supports.
“Two million times each year, people with mental illness are booked into our nation’s jails,” Wesolowski says. “It is notoriously difficult to get mental health treatment in a criminal justice setting.”
Lisa Dailey, executive director of the Treatment Advocacy Center, says law enforcement’s involvement in mental health emergencies is a symptom of the longstanding gaps in the public mental health system.
The advent of 988, she says, is an opportunity for health care and social services to step up.
“Over time it should be obvious that this is a better system,” Dailey says.