One year after the creation of the three-digit crisis hotline known as 988, officials say the next step is expanding awareness and local crisis care.

More than 4 million people have called, texted or chatted the suicide prevention hotline in the year since its creation, according to Laurel Stine, executive vice president and chief policy officer for the American Foundation for Suicide Prevention.

She estimates that number will grow in the next fiscal year to 9 million contacts.

“We have to be mindful that Rome was not built in a day,” she said. “We’ve had a fragmented mental health behavioral health crisis system for a number of years.”

Since July 16, 2022, dialing or texting 988 directs individuals to the 988 Suicide and Crisis Lifeline — where they can speak to a trained crisis counselor and be connected to resources related to mental health, emotional distress, grief or substance issues for themselves or a loved one.

Mental health experts say the implementation of the universal, simplified number is the first step to ensuring broader access to crisis care and subsequent support or stabilization.

“I think from a state level and a federal level we really were focused on implementation,” Monica Johnson, director of the 988 & Behavioral Health Crisis Coordinating Office at the Substance Abuse and Mental Health Services Administration, told CQ Roll Call.

Johnson, who took on the role in January after leading implementation on a state level, said the next step will be educating and expanding awareness about the tools that exist.

Last year’s U.S. launch spurred Canada to take similar steps: Canada’s own national 988 implementation is set for Nov. 30, 2023.

Next steps

The process of building a comprehensive crisis care system for mental health is no easy feat given logistical and budgetary restrictions and unforeseen circumstances. The widespread adoption of 911 in the 1960s and ’70s was a yearslong process.

“I think 988 has really provided a catalyst for the entire field to think about the crisis continuum,” said Kelly Clarke, vice president of the 988 Lifeline at Vibrant Emotional Health, which administers the line. “We want to make sure that that continuum works in collaboration with each part of the continuum — that we don’t have sectors that are working in silos.”

In the first year, the lifeline reported nearly 5 million contacts through calls, chats and texts – or double the previous year through the 10-digit number, including 1 million to the Veterans Crisis Line, which military members, veterans and their families can reach by dialing 988 and pressing option 1.

Compared to before the launch, texts increased by 1135 percent, chats increased by 141 percent and calls increased 46 percent. SAMHSA said average answer time dropped from 2 minutes and 39 seconds to 41 seconds.

Data on the nation’s mental health crisis, particularly since the pandemic, has been stark. For example, Centers for Disease Control and Prevention data published in February found almost one-third of teen girls “seriously considered” suicide in 2021.

But Johnson said that so far, the existing infrastructure has had the capacity to support the increased demand.

“This is not a ‘one and done,’ so I imagine the demand is going to continue to increase as people become more aware of the number,” she said.

SAMHSA plans to prioritize education and equity going into the second year, by educating more individuals about the lifeline and when it can be used instead of a 911 emergency call for paramedic or police assistance.

Stine emphasized the need for outreach to groups including rural areas, unhoused individuals and tribal communities.

This year, Vibrant and SAMHSA aim to roll out a video calling option for deaf and hard-of-hearing individuals who communicate using American Sign Language.

“We’ll continue to look for opportunities to make sure that it is equitable. We have those conversations with our federal partners every day now, as well as our advocacy, community and other partners,” said Johnson.

Congress

Advocates have praised the hotline and its ability to accommodate an influx of calls as a launch pad for expanding mental health resources.

“I think we’ve seen bipartisan support for this work and think we’ve seen that federally … as well [as] locally in states,” Johnson said.

The White House budget seeks $836 million for 988 efforts for fiscal 2024 — a $334 million increase from current enacted levels. It also seeks $100 million for mobile crisis response, which are rapid behavioral health assessments and interventions. That request is $80 million more than current spending. Neither chamber has released a Labor-HHS-Education spending bill yet.

Senate Labor-HHS-Education Appropriations Subcommittee Chair Tammy Baldwin, D-Wis., said she is “hopeful” despite “limitations we’ve seen because of the debt deal” that they’ll be able to prioritize funding for 988, SAMHSA and mental health research.

Baldwin, who co-sponsored the law that designated 988 as the national suicide and crisis hotline, said Wisconsin’s call center went from answering about 1,000 calls a month in 2021 to 4,500 calls a month following the launch.

“We cannot let our guard down. We have to continue to invest in this proven tool to save Americans lives,” she said.

Baldwin also emphasized the need to meet specialized needs of certain populations at higher risk for suicide, such as farmers and farm workers who face increased stress, isolation and financial constraints and live in more rural areas. She said they are working to ensure farmer mental health is prioritized in this year’s farm bill.

Rep. Tony Cardenas, D-Calif., meanwhile, plans to reintroduce legislation providing federal guidance to and authorizing funding for state and local crisis services and call centers.

As with any major launch, the launch of 988 has not been without hiccups. The lifeline experienced an almost day-long outage in December 2022 caused by a cyberattack.

Separate bills seek to beef up the lifeline from cybersecurity threats and increase reporting requirements to identify future vulnerabilities.

States

State-level action to support the rollout has taken different forms.

So far, eight states have passed legislation adding a telecom fee to phone bills, similar to 911, to fund 988 crisis efforts, according to the National Alliance on Mental Illness.

Stine said work needs to continue to strengthen the 988 call centers and build capacity for mobile crisis response as well as stabilization centers, all of which will require sustained funding.

“That means there’s a lot of states that still need to announce the legislation, whether it’s telecom fees, which is a sustainable source of funding, or build out a source of funding that’s comprehensive in scope,” said Stine.

Advocates also see an opportunity to do more.

“In our ideal world, comprehensive state legislation would not just include a fee. It would also include detailed language about how the state will take up its Medicaid option and how it will require commercial insurance reimbursement,” said Lauren Finke, a policy director at The Kennedy Forum, a mental health organization founded by former Rep. Patrick J. Kennedy. “We haven’t seen much of that.”

The 2021 COVID-19 relief law allowed states to seek enhanced federal Medicaid funding for covering mobile crisis services. Finke wants more states to pursue this option.

“That’s federal money being left on the table,” she said.

Finke also said states should enact stronger legislation and enforcement mechanisms to require commercial insurers to cover emergency behavioral health services. Washington state, she said, took steps last year to ensure that plans must adhere to federal and state parity requirements for emergency crisis services.

This week, California Gov. Gavin Newsom also signed the state budget for 2023-24 that would strengthen coverage of crisis behavioral care.

“We think you can do it with existing federal levers, but of course it makes it much easier when states both take actions to clarify that and really take action to require those core services be covered,” Finke said.

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If you or someone you know is facing a mental health crisis, please call the toll-free, 24-hour 988 Suicide and Crisis Lifeline at 9-8-8 to be connected to a trained counselor.