Why access to suicide prevention services is easier in one crucial way

Last year the federal government deputed a three-digit suicide prevention hotline phone number. 988. It replaced a 10-digit number. The new number is thanks to ...

Last year the federal government deputed a three-digit suicide prevention hotline phone number. 988. It replaced a 10-digit number. The new number is thanks to the work of a team at the Substance Abuse and Mental Health Services Administration. Team members are now finalists in this year’s Service to America Medals Program. Federal Drive with Tom Temin spoke with two of the finalists, James Wright and Dr. Richard McKeon.

Interview Transcript: 

Tom Temin And let’s begin with why. I mean, it’s easier to remember 988 than it is to remember whatever the old number was. But it sounds like there’s more to it than just simply a three digit phone number. Tell us more about this program.

Richard McKeon Well, I can start, James. So certainly one part of it is that it’s easier to remember. And part of the context for that, is that we want it to be easier to remember for people, but particularly when they’re in a crisis. One thing that SAMHSA said in our report to the Federal Communications Commission when we were asked to weigh in on whether a three-digit-number was feasible and whether it could be effective is that we indicated that, for example, if someone was having chest pains and they were with a family member, it’s likely, despite the stress of that situation of the medical crisis, that both the person and the family member are going to remember the number 911, but that they were not in a similar situation in a suicidal crisis. It was unlikely that either the family member or the person themselves would remember the ten-digit-number. We additionally felt that when you looked at the history of 911, it played a catalytic role in promoting the development of emergency medical services in America. So in our report to the FCC, we also indicated that we thought a three-digit-number could play a similarly transformative role in behavioral health crisis services across the country. And we have been very gratified the extent to which that vision has been subscribed to by states, localities, providers and crisis centers across the country.

Tom Temin And just a detail question, it is easier to remember clearly 988 than, again, the old number, which I don’t have at the top of my head either. But more than easier to remember a time of crisis. Is there the phenomenon that because it’s easy to remember, someone might be more likely to dial that number and therefore seek the help they need? It seems like a slight difference, but I think there’s a distinction there.

James Wright Absolutely there is. I mean, at the heart of 988 is the ease of access, but also it is easier to embed within communications. Hopefully really bringing down stigma of seeking help for mental health concerns. And so we’re seeing this play out as we see youth and young adults specifically increase access to 988, especially for chat and text services, which I’m sure we’ll get into later.

Tom Temin And let’s set the scene here. I mean, how many annual calls was the old 800 number getting? I mean, what’s the extent and scope of this whole situation in the first place?

James Wright Yeah, looking back, the old 800 number from the inception, I think the very first year we were a little bit under 50,000 contacts total. In 2022, we had reached between three and 4 million contacts. We say that, because we launched in the middle of 2022. Since then we’ve seen a significant increase of phone chat and text. Phone was right under 50% of increase with the transition to 988. But our biggest increase has been chat and text, specifically text. This is the first time we activated fully that number, and since then it has been consistently over 1,000% increase.

Tom Temin Wow. So someone can text to that same number and someone will be there to answer that text?

James Wright That is correct.

Tom Temin We’re speaking with James Wright. He is director of crisis operations and Dr. Richard McKeon, senior adviser in the 988 program at the Substance Abuse and Mental Health Services Administration. They’re both finalists in this year’s Service to America Medals Program. And is there any way of measuring the quality of a certain call? That is to say, if there were 50,000 a year, probably safe to say everyone that called really wasn’t a crisis with 988 being so easy and accessible. Are they all real suicide calls? Is there a way of determining that?

Richard McKeon Well, we do have some information on that. First of all, there is has been a series of evaluation studies led by Dr. Madelyn Gould at Columbia University that has looked at the effectiveness of calling a lifeline. Now, these studies were all done pre 988. And what it found was that callers had suicidal ideation and hopelessness reduced during the call. They also did show that there could be some recurrence of suicidal ideation over the next six weeks, which led us to promote the importance of follow up calls as a part of what crisis call centers ought to be doing. The evaluation studies also showed that even if your callers who are at imminent risk for suicide, that in many instances their risk was able to be reduced enough on the phone that emergency intervention was not needed, making access to 988, an important alternative to 911 in the use of emergency services, including police and emergency medical services in those kinds of situations. Now for chat and text, we actually have more information, because there is a pre-chat and pre-text survey. And there what we know is that the majority of the people who chat and text are currently suicidal. For callers, it is about 18%, I think, of callers who are currently suicidal. Others might have been suicidal in the past, but not at the moment. Or they could be a third party caller, someone, a family member calling about a loved one. But someone doesn’t have to be suicidal in order to call 988. For example, if somebody is feeling depressed and hopeless, we certainly don’t want them to have to wait until they’re suicidal to call. We want them to call earlier, or if it is another kind of behavioral health crisis, we want them to be able to call. They do not have to be suicidal at the time in order to call.

Tom Temin And with a 50% increase or 1,000% increase in texts and calls and so forth, who answers these calls and texts, and what did you have to do on the back end to make sure that when someone does call with calls up 50%, it’s not like the IRS, nobody answers.

James Wright Yeah, no, it’s a great question. And again, that was that was with the transition to 988. We continue to see our contacts increased month over. And so those those don’t stay stagnant. But we do have actually that data publicly posted on SAMHSA website and go to SAMHSA.gov/988, and there’s a performance metrics tab, which we really want to make sure we’re as transparent as possible with the outcomes of this program. The way that the system is set up is we have over 210 crisis centers across the nation in every state, and when you call 988 you’re provided a list of options to connect to care. If you choose those, you can be connected to the Veterans Crisis Line or our Spanish services. We were proud to extend our services further to offer direct services for LGBTQ youth at the end of September of last year, and then otherwise you would be routed to your nearest crisis center. You can also find out where those crisis centers are on the 988 Lifeline Board website, and we do route currently by area code looking at ways to continue to improve reaching those local crisis centers with those direct calls.

Tom Temin But do more people have to be added to the crisis centers to handle the volume?

James Wright It’s a great question, because workforce has been a significant priority with SAMHSA and 988, and the states helping support crisis centers. Funding went out from SAMHSA to states and territories, to build a workforce specifically prior to the transition of 988. And so, yes, it has taken a tremendous effort from states in crisis centers to plan for 988 and to help respond to the increased demand.

Tom Temin And earlier, you mentioned in reports to the FCC, what is required to establish a three-digit- number? And it sounds like the FCC has the say over this.

Richard McKeon Yes, absolutely. It’s a fascinating story. The effort actually started in the state of Utah, because they wanted a three-digit-number for suicide prevention in Utah. And what they learned is that that’s not something that a state could do, because the Federal Communications Commission has authority over that. And so they work with their congressional delegation. We worked in a bipartisan fashion to ultimately pass the National Suicide Prevention Lifeline Improvement Act, which asked for SAMHSA and the Veterans Administration to do reports to the Federal Communications Commission about whether a three-digit-number was advisable and could be effective. SAMHSA and the VA did those reports, and our report strongly supported a three-digit- number. And under that same law, the FCC was required to report to Congress on whether a three-digit-number was advisable, and to make recommendations. And the FCC, in their report to Congress, recommended 988 be that number. And that was followed by the National Suicide Hotline Designation Act, which put 988 into law as the new number. And then the FCC oversaw the access to 988, because every cell phone, every landline, every voice over Internet device in the United States had to have 988 made operable. And so the FCC oversaw that. SAMHSA’s role was to oversee that there would be the capacity to answer the calls, the chats, the text by  the date of July 16, 2022, that the FCC had set.

Tom Temin Yeah, that is an interesting story. And just again, a detailed question, Why not 999, 977?

James Wright That’s a great question. And the FCC did a thorough review of those of options of three digit options, many of which may have area codes that are currently being utilized across the nation. And then others, they had to evaluate for international dialing codes. So really, when it came down to it, they identified that 988 was an easy to remember number. And it really had, from their understanding, the least amount of impact for a transition itself. There was no area code that started. There was no 988 area code. So they didn’t have to worry about that. They just had to worry about places without allowed within area code dialing, without dialing the area code that started with 988. And there were a bunch of those that the FCC had to work with to make changes.

Tom Temin And just a final question philosophically, I guess. Over time, is there an effort to understand suicide itself based on analytics applied to the content of these millions of calls and chats?

Richard McKeon Well, I think, there is certainly analytics that are being applied to suicide prevention in general. Nothing like that is happening regarding calls, chats and texts to the lifeline. As I said, I have been in evaluation studies in the past. We are planning evaluation studies for the future. But that kind of automatic use of data is not part of what happens with 988. And we want people to feel comfortable knowing that their information is secure when they contact us, unless there is a life and death emergency that requires an emergency intervention.


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