One year after launch, 988 mental health crisis line still building awareness and staffing

By Jacqueline Howard and Giri Viswanathan, CNN

(CNN) — Thanks to a trio of digits — 988 — the past year has been “transformative” in the United States’ ongoing efforts to tackle the nation’s mental health crisis, according to health officials. But as it heads into its second year of existence, the three-digit number for the country’s mental health crisis lifeline still has some hurdles to overcome when it comes to awareness, staffing and routing.

The 988 Suicide and Crisis Lifeline, formerly known as the National Suicide Prevention Lifeline, transitioned last year from 1-800-273-TALK to a simpler dial code, 988. Those three numbers are intended to be easier to remember, like 911 for emergency medical services.

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.”

Almost 1 million of the nearly 5 million contacts were linked to the Veterans Crisis Line, which military members, veterans and their families can reach by dialing 988 and pressing option 1.

Compared with the 12 months before the launch last July, text messages through the lifeline increased by 1,135%, chats answered increased by 141% and calls answered increased by 46%, according to the HHS data. The average speed to answer for contacts decreased from 2 minutes and 39 seconds to 41 seconds.

The Biden-Harris administration has invested nearly $1 billion in the initiative. Much of that investment has gone directly to states, territories, and tribes to hire crisis counselors and improve local response, according to HHS officials.

“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 behavioral 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 behavioral 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 behavioral health care. This has not happened before.”

Yet many people still don’t know that the lifeline exists or that 988 call centers face ongoing staffing challenges – and are actively seeking counselors.

More than 80% of US adults not familiar with 988

Most people across states and territories don’t know that they can call, text or send a chat online to 988 to reach licensed counselors trained to de-escalate a crisis, provide emotional support or connect them with additional mental health resources.

A new poll from the National Alliance on Mental Illness (NAMI) released Thursday found that 82% of adults were either unfamiliar with or had never heard of the 988 Suicide and Crisis Lifeline. Only 17% were “very” or “somewhat” familiar with the service.

Conducted in collaboration with the marketing research firm Ipsos, the poll surveyed about 2,000 adults nationwide 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.

More than half, 51%, of respondents said they did not believe police should respond to a 988 call. Even more respondents, 74%, did not know if a 988 call would always result in an emergency response.

But the vast majority of calls to 988 — some experts estimate more than 98% — do not escalate to emergency services being dispatched.

“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.”

Young adults ages 18 to 29 were more likely to be familiar with 988 than older Americans, the survey found. Similarly, LGBTQ+ adults were more than twice as likely to report familiarity with 988 than their non-LGBTQ+ counterparts. The 988 lifeline offers callers the option to connect with a counselor trained explicitly to support LGBTQ+ youth and young adults by pressing option 3 after they dial the number.

“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.”

SAMHSA and Vibrant Emotional Health, the nonprofit administrator and operator of the 988 lifeline, plan to launch an awareness campaign this fall to help spread the word about the three-digit number, said Tia Dole, chief 988 Suicide & Crisis Lifeline officer for Vibrant Emotional Health.

“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 call for more crisis counselors

Many 988 call centers have announced that they need more licensed counselors 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.

The 988 network includes more than 200 centers responding to people in crisis, and those centers are seeking volunteers as well as paid employees. The 988 website lists job postings and volunteer opportunities across 50 states and territories. HHS announced in May that more than $200 million in 988 lifeline grants will be awarded in late Fiscal Year 2023 to support states, territories, and tribes as they build out local capacity for crisis services.

This call for more crisis counselors is emerging amid a broader shortage of health-care workers across the United States.

“Workforce challenges is a real thing,” Johnson said. “This remains an ongoing challenge.”

Sometimes, Vibrant Emotional Health will provide advice to call centers on how to help recruit staff and will share strategies that have helped other centers build and retain counselors, 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 counselor.”

Crisis counselors are in need of support, Wesolowski said, and call centers 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.”

The shortage of 988 call center counselors can vary by state. And since 988’s launch, there have been state-by-state differences in the implementation and funding of the crisis line.

Now, at the one-year mark, states have established separate plans for how to either integrate 988 into existing crisis call systems or maintain new separate systems for 988.

“That’s still being navigated by states,” said Hemi Tewarson, executive director of the nonprofit National Academy for State Health Policy (NASHP), which has been tracking state-enacted legislation to fund and implement 988.

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 behavioral health and social services providers in their state.”

For instance, “Indiana enacted a law that creates a behavioral health commission, and they’re going to issue a report on the statewide implementation of 988 by August 1, 2024,” she said. And across the country, in Washington state, “they passed legislation that updates their state requirements related to 988,” such as requiring reports on 988’s performance and funding aspects.

“From all of my many years in state health policy, seeing behavioral health and the health care workforce coming to the top like this is a shift,” Tewarson said. “To have legislators and governor’s offices and other senior state leaders who are not the behavioral experts or the health care workforce experts really express that this is a priority area for them, I think, underlines the crisis and the challenges we have in providing access to needed services.”

The concept for 988 was first proposed to Congress by the Federal Communications Commission in August 2019, and then the National Suicide Hotline Designation Act was signed into law in 2020, authorizing 988 as the new three-digit dialing code for suicide and mental health crises.

“When the FCC started our work on 988 several years ago, I encouraged our agency to explore incorporating texting into the Lifeline. It shouldn’t make a difference how you reach out in an emergency, but that you can connect to mental health resources, no matter how you communicate,” FCC Chairwoman Jessica Rosenworcel said in a news release Thursday.

“In the past year, both text and chat have become an integral part of the 988 Lifeline. And now, that reach is further expanded to Spanish speakers, who can communicate in Spanish by text and chat for the first time,” Rosenworcel said. “I’m extremely proud of the work that our agencies have done to make this life-saving service more accessible to those who need it most.”

Up next: Ironing out routing issues

As for what else the future holds for 988, the lifeline is rolling out text and chat features in Spanish this week and there will be future efforts to route calls, texts and chats to call centers in the same geographic area as the user, called geo-routing, Johnson said.

Currently, calls are routed to centers in the same geographic location as the user’s area code. For instance, someone based in Los Angeles who has a cell phone number with a New York area code would reach a center in New York. That call center would then need to route the call to a center 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 centers that know what local resources exist,” Wesolowski said. “It’s those local call centers 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.”

Getting people connected to local resources can reduce the number of people seeking mental health care in a hospital emergency department, said Dr. Mariam Betz, an emergency medicine physician and professor at the Colorado School of Public Health in Denver, who is not involved in 988.

“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 center 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 a human contact in these moments that are very distressful for people who are often reaching out.”

CNN’s Mandy Nottingham contributed to this report.

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