According to health officials, the past year has been “transformative” in the United States’ continuous attempts to address the country’s mental health crisis because of a trio of digits: 988. The three-digit number for the nation’s mental health crisis lifeline still needs to clear certain obstacles in terms of awareness, staffing, and routing as it enters its second year of operation. The National Suicide Prevention Lifeline, now known as the 988 Suicide and Crisis Lifeline, changed last year from 1-800-273-TALK to a more user-friendly call code, 988. Similar to how 911 is used for emergency medical assistance, those three numbers are meant to be simpler to remember.
Sunday marks the first anniversary of 988’s launch, and there have been nearly 5 million calls, texts and online chat messages answered through 988 in the year since its launch, according to data released Thursday by the US Department of Health and Human Services. “That is well over a million, close to 2 million, more than what we saw in previous similar time frames,” HHS Secretary Xavier Becerra told CNN. “We now have to make sure that we continue to build the end of the pipeline, which means once they’ve called in, we’ve got to make sure they’re getting services as well.”
The Veterans Crisis Line, which military members, veterans, and their families can contact by dialling 988 and selecting option 1, was connected to about 1 million of the roughly 5 million contacts. According to HHS data, text messages sent through the lifeline surged by 1,135%, chats were responded to 141% more frequently, and calls were answered 46% more frequently than they were in the 12 months prior to the introduction last July. From 2 minutes and 39 seconds to 41 seconds, on average, it took contacts to respond. The project has received approximately $1 billion in funding from the Biden-Harris administration. According to HHS officials, a large portion of the funding has gone directly to states, territories, and tribes to hire crisis counsellors and enhance local responsiveness.
82% of Americans either were not familiar with or had never heard of the 988 Suicide and Crisis Lifeline
“This is a three-digit number, easy to remember — 988 — you can call it, text it or chat when you feel like you need support, whether that’s for depression, sadness, anxiety, whatever it may be,” said Monica Johnson, director of the 988 & Behavioral Health Crisis Coordinating office at the US Substance Abuse and Mental Health Services Administration (SAMHSA). The 988 lifeline is supported by HHS through SAMHSA. “This is the most transformative initiative in behavioural health care that I have seen in my career, and I don’t say that lightly,” said Johnson, who has been working in mental health for 26 years.
“Every single state and US territory is having a conversation at the same time about their behavioural health crisis system, which leads you to a conversation about, ‘How do you prevent? How do you do earlier services? Let’s talk about prevention.’ Then it leads to a conversation about, ‘What happens after the crisis?’ ” she said. “Now you have a conversation about a whole continuum of care related to behavioural health care. This has not happened before.” Yet many people still don’t know that the lifeline exists or that 988 call centres face ongoing staffing challenges – and are actively seeking counsellors.
The majority of individuals in all states and territories are unaware that they can contact licenced counsellors who are trained to defuse a crisis, offer emotional support, or connect them to other mental health resources by calling, texting, or chatting online at (988). According to a recent NAMI poll issued on Thursday, 82% of Americans either were not familiar with or had never heard of the 988 Suicide and Crisis Lifeline. Only 17% of people rated the service as “very” or “somewhat” familiar. The poll, which was conducted in association with the marketing research company Ipsos, questioned 2,000 persons across the country in early June. While most respondents didn’t fully understand what 988 offered, more than 3 in 5 were aware of its existence — a 19% increase from the last NAMI/Ipsos poll in September 2022.
51% of respondents, or more than half, disagreed that police should respond to a 988 call. Even more respondents, 74%, were unsure of the frequency of emergency responses following 988 calls. However, the overwhelming majority of calls to 988 — some analysts estimate more than 98% — do not progress to the deployment of emergency services. “The intervention often is the call,” Johnson, who was not involved in the survey, said. “One of the biggest challenges — with probably anything new — is the education and the communication around that the number exists, that this is even a service that is out there.”
The survey discovered that younger Americans (ages 18 to 29) were more likely than older Americans to be familiar with 988. Similarly, compared to non-LGBTQ+ people, LGBTQ+ persons were more than twice as likely to report familiarity with 988. By selecting option 3 after dialling the 988 lifeline number, callers have the option of speaking with a counsellor who has been specially trained to support LGBTQ+ children and young adults. “We have a lot of education to do,” said Hannah Wesolowski, NAMI’s chief advocacy officer. “There are a lot of people in need, and this is a resource that can be beneficial to folks.”
According to Tia Dole, chief 988 Suicide & Crisis Lifeline officer for Vibrant Emotional Health, SAMHSA and the nonprofit organisation that manages and operates the 988 lifelines intend to begin an awareness campaign this autumn to promote the three-digit number. “We engaged with a few different firms to help us with a national campaign. And my guess is that the campaign will start generally, and then from there, we’ll market specific populations,” Dole said. “The messaging is, ‘We are here,’” she said. “Call us if you have any questions, call us if you’re in a crisis, call us if you are really struggling with your mental health, struggling with depression, anxiety, racism.”
A plea for additional crisis counsellors
Many 988 call centres have announced that they need more licensed counsellors to answer the influx of calls, texts and chat messages. “We know that demand for 988 is only increasing,” Wesolowski said, adding that calls, texts and chats are projected to rise to 6 million this year and 9 million next year. More than 200 crisis response centres are part of the 988 network, and both volunteers and paid workers are needed at these facilities. The 988 website features volunteer and career postings from all 50 states and territories. In May, HHS announced that 988 lifeline grants totalling more than $200 million would be given to states, territories, and tribes to help them expand their local capacity for crisis services. There is a growing need for more crisis counsellors across the United States due to a general scarcity of healthcare workers.
“Workforce challenges is a real thing,” Johnson said. “This remains an ongoing challenge.” Sometimes, Vibrant Emotional Health will provide advice to call centres on how to help recruit staff and will share strategies that have helped other centres build and retain counsellors, Dole said. “I think the biggest challenge for them is worker burnout,” Dole said. “The nonprofits that offer remote work are the ones who have the easiest time staffing,” she added. “I think that there’s more work to be done, from my perspective, around the wellness of the individual counsellor.” Crisis counsellors are in need of support, Wesolowski said, and call centres could do more to retain their staff.
“We need to keep the people we have as well as get more into the workforce and taking care of their mental health and wellbeing is paramount,” she said. “They’re dealing with people on the worst days of their lives.” State-by-state variations exist in the 988 call centre counsellor shortage. Additionally, there have been variations in the implementation and funding of the crisis line on a state-by-state basis since the inception of 988. After a year, each state has developed a unique plan for how to either maintain the new standalone systems for 988 or integrate them into the current crisis call systems.
According to Hemi Tewarson, executive director of the nonprofit National Academy for State Health Policy (NASHP), which has been tracking state-enacted legislation to fund and execute 988, “that’s still being navigated by states.” As of early June, more than half of states — at least 26 so far — have enacted some form of legislation to fund and implement the 988 Suicide and Crisis Lifeline, according to NASHP’s data. “All states have set up 988, and it’s running, and it’s in operation. Even if there’s a state that’s not listed as having legislation this session, they could be doing some of this work outside of enacting legislation,” Tewarson said. “And there are some commonalities in terms of how states are thinking about funding and the oversight pieces and the connections to EMS and the other behavioural health and social services providers in their state.”
Next: Resolving routing problems
In terms of what else lies ahead for 988, Johnson noted that this week will see the launch of text and chat options in Spanish and that efforts would be made in the future to geo-route calls, texts, and chats to contact centres that are close to the user. At the moment, calls are forwarded to locations close to the area code of the user. A person in Los Angeles who had a cell phone with a New York area code, for instance, would be able to contact a centre in New York. That call centre would then need to route the call to a centre in Los Angeles so someone can direct the caller to the most relevant information on local services such as mental health, housing or food security resources.
“We know that the best outcomes happen when a call is answered locally because it’s those local call centres that know what local resources exist,” Wesolowski said. “It’s those local call centres who are able to make that connection and make sure we’re not just dealing with the immediate crisis, but we’re helping people connect to the resources that are going to support them long-term.” According to Dr Mariam Betz, an emergency medicine physician and professor at the Colorado School of Public Health in Denver who is not affiliated with 988, connecting people to neighbourhood resources can decrease the number of people seeking mental health care in hospital emergency departments.
“What we really want to do is match people to the services they need, and so if this also frees up ambulances and it frees up police, then that’s a great ultimate outcome,” Betz said. 988 routing differs from 911, which connects callers to the call centre closest to their geographic location. “What we’d like to do as we continue to evolve is get you closer beyond just the area code,” Johnson said. “So we are exploring ways in which we can look at routing opportunities that don’t just depend on your area code.” But as far as other advancements, such as using chatbots or artificial intelligence to help respond to calls, Johnson said that was unlikely any time soon.
“We don’t see AI playing a role with 988 as it relates to the call. We want people to be connected to another person – so rather that’s via the call, text or chat,” she said. “Right now, we’re not interested in seeing how AI can work with people that are reaching out to be connected. We want people to have human contact in these moments that are very distressful for people who are often reaching out.”