988, one year later: Has the rollout of this crisis lifeline actually improved mental health?

For the last year, three memorable numbers could make a big difference in someone's life: 988. Americans with phone access, whether cellular or landline, could dial or text the three-digit code to receive suicide prevention and mental crisis support. The service, which is free, anonymous and available 24/7, was introduced as an update to the 1-800-273-8255 number, which can be harder to remember.

However, just because the 988 Suicide & Crisis Lifeline exists doesn't mean that every American experiencing a mental crisis in the last year used the 988 lifeline or even knew about it.

In the 11 month period ending May 31, 2023, over 4.5 million calls were made to the 988 lifeline. However, the untrackable number is how many people didn't call. Those who weren't aware of the crisis line are unable to be accounted for, whether due to stigma or just lack of awareness.

Instantaneous mental health support and telehealth have increasingly become a staple of suicide prevention at a time when it is a leading cause of death for Americans. In 2021, suicide was the second-leading cause of death for those aged 10 to 14 and 25 to 34, according to data from the Centers for Disease Control and Prevention. The COVID pandemic marked not only a rise in suicide but also the use of virtual mental health care.

It's no easy task maintaining a workforce of dispersed and independent 988 call centers, but despite this, roughly 469,000 callers in May 2023 faced a drastically lowered wait time: Just 35 seconds on average, according to the U.S. Department of Health and Human Services' SAMHSA, which is a significant drop from the previous average of 140 seconds.

"A year ago we were saying, would it work? Would the demand outpace the capacity?" Bob Gebbia, CEO of the American Foundation for Suicide Prevention, told Salon.

So far, Gebbia's questions seem to have been answered, as contacts are up and wait times are down.

A monthly call volume approaching half a million represents a significant increase from the 46,000 calls the National Suicide Prevention Lifeline fielded in 2005, its founding year. The number gained popularity following the 2017 release of the song "1-800-273-8255"' by the American rapper Logic, which according to the journal BMJ, further destigmatized the use of a crisis line.

Despite the increased awareness, in 2020 the FCC required a simpler number be designated for a national suicide prevention and mental health crisis line, slated for activation by all U.S. telecommunication providers by July 16, 2022.

A year later, Gebbia is predicting 988 will receive five to nine million calls in its second year, up from nearly 4.5 million in year one of its operation. This increase is due to a slew of factors, including increased awareness and a decreasing stigma. However, a huge swath of Americans are seemingly unaware of the 988 lifeline's existence, with an estimated 75% still in the dark, according to Gebbia. A recent poll by The Pew Charitable Trusts found an even greater disparity, with only 13% of adults having heard of the lifeline and its purpose.

For someone experiencing a mental crisis, this gap in public awareness is likely one of the reasons leading them to neglect calling 988 or instead dial 911. As 911 and 988 haven't been widely integrated with one another, this may only be beneficial under certain scenarios. Not only are behavioral health calls to 911 not guaranteed to be rerouted to 988, a 911 call all too frequently leads to the unnecessary dispatch of law enforcement to a mental health crisis.

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This avoidable response is increasingly becoming lethal. To cite one example, Raul de la Cruz, a mentally ill man living in the Bronx, was shot by police within 28 seconds of law enforcement arriving at his father's apartment. According to the New York Times, last year "police responded to about 171,000 calls about 'E.D.P.s' — emotionally disturbed people."

With the expected increase of 988 calls in year two, Gebbia and others are worried about the already strained mental health workforce being unable to sustain capacity. This industry-wide concern is why Gebbia has been advocating before Congress for an increase in federal funding. His call to raise the lifeline's annual $500 million budget to $800 million could mean higher pay to incentivize participation in the mental health workforce.

"I would hope that with our allies in Congress who are really mental health champions, that they will fight for additional money," Gebbia said. "This is not a Republican or a Democratic issue."

Every 988 Lifeline center operates independently of one another, so the workforce challenges can be manageable in one area while another lacks a mental health workforce.

The Biden-Harris Administration has invested nearly $1 billion toward the 988 Lifeline, including $200 million this past May. The recent funding expanded local capacity for the 988 Lifeline, including funding geared (and available now) specifically toward federally recognized Indian Tribes, tribal organizations, and Urban Indian Organizations. It also included follow-up care of suicidal persons who called the 988 Lifeline.

Given that mental health is a highly stigmatized topic, one often engulfed in stereotypes, many misunderstandings surrounding the 988 Lifeline may exist after a year of its use. Importantly, the lifeline can be contacted by anyone in emotional distress, not only those experiencing suicidal ideation, Dr. Tia Dole, Chief 988 Lifeline Officer at Vibrant Emotional Health told Salon by email. In a society that is still known to promote the notion that it is "not okay to not be okay," it can be presumed there is room for progress on the front of non-emergency mental health cases utilizing the lifeline.

"Unfortunately, so many people avoid asking for help and seeking help that then they wait until they're in crisis and that's when they need 988," Gebbia said. "We'd love to see 988 avoided if we could."

Instead, Gebbia hopes individuals will receive adequate mental health support prior to ever being in a crisis and needing the lifeline. However, there is no prerequisite to calling 988. The service is open to anyone, whether experiencing a crisis or not.

Another possible public misperception is that callers will be outed or have a professional arrive at their door following a call. However, there is no way for callers to be tracked, as 988 doesn't enable geo-location sharing. The only information the mental health professional receives is that which the caller voluntarily shares.

Some stigmatized barriers like this are exacerbated in historically marginalized communities. For Black individuals experiencing suicidal thoughts or a mental health crisis, the commonly held fear of police arriving following a 988 lifeline call is ever present, according to Gebbia. This disparity in cultural adoption, access to care and equitable rollout is similar to the mobile response units cities are actively rolling out to appropriately respond to mental health crises.

This city-by-city rollout is to prevent law enforcement, who aren't typically trained in mental crisis de-escalation, from arriving on the scene of a behavioral health crisis. Despite stigmas and stereotypes, mentally ill individuals are significantly more likely to be the victims of violence than perpetrators. However, these mental health response units aren't always efficiently linked to the local 988 lifeline, a city-by-city logistical feat that Gebbia is hopeful will change.

Further work to address equitable access was taken just this month when the Lifeline's LGBTQI+ pilot line became a permanent LGBTQI+ subnetwork. This addition, which comes with the option of connecting a caller with a counselor trained explicitly to support LGBTQ+ community members, is part of the lifeline's efforts to serve specific demographics often experiencing a heightened risk of suicide, such as veterans.

"This social responsibility relies on all of us, including federal, state, and local governments, public and private payors, to ensure that life-saving interventions are continuously available as quickly as possible," Dr. Dole told Salon by email.

Judging from these baseline measurements, year one of the 988 lifeline has been a success. More calls are answered, (45% year over year ending May 2023), while wait times have fallen from over two minutes. If the stigma of seeking mental health care continues to fade, it is likely more calls to 988 will be dialed, which means the workforce fielding these calls can expect a greater workload. As far as equitable reach and a sustainable workforce, mountable hurdles are ahead for 988 to become more than just a number and actually measurably decrease rates of suicide.