The National Suicide Prevention Lifeline’s 988 telephone number, launched on July 16, was designed as a universal mindset support tool for callers anytime anywhere.
But the United States is a patchwork of resources for crisis relief, so what comes next is not universal. The level of support 988 callers receive depends on their postcode.
In particular, rural Americans, who die by suicide at a much higher rate than residents of urban areas, often have trouble accessing mental health services. While 988 connects them to a call center close to home, they can end up being directed to far away resources.
The new system is supposed to give people an alternative to 911, but callers from rural areas experiencing a mental health crisis may still be met by law enforcement personnel, rather than mental health professionals.
More than 150 million people in the United States—most from rural or semi-rural communities—live in places designated as mental health professional shortage areas by the Federal Health Resources and Services Administration. This means that their communities do not have enough mental health providers – usually psychiatrists – to serve the population.
The Biden administration has allocated about $105 million to states to help increase local crisis call center staffing for the new 988 system. But states are responsible for filling any gaps in the continuum of care that callers rely on when they need more than a phone call. States also assume most responsibility for staffing and funding their 988 call centers when federal funding dries up.
The federal Substance Abuse and Mental Health Services Administration, which runs the existing 800-273-8255 lifeline that expands 988, said a state that launches a successful 988 program ensures that callers have a mental health professional to talk to , a mobile crisis team to respond to them, and a place to go — such as a short-term crisis stabilization facility — that offers diagnosis and treatment. The federal agency also wants to reduce reliance on law enforcement for 988, expand access to mental health care and relieve pressure on emergency rooms.
These goals may not play out equally in all states or communities.
If a call center doesn’t have a mobile crisis team to dispatch, “you don’t have stabilization, you basically go from the call center — if they can’t meet your needs — to the emergency room,” said Dr. Brian Hepburn, executive director of the National Association of State Mental Health Program Directors. The group developed model 988 legislation for states that emphasizes the need for consistent services regardless of call location.
For the new call system to be consistent, “you really need the full continuum of care,” Hepburn said. “The expectation is not that it’s available now. The expectation is,” he said, “your state would eventually get you there.”
But when 988 was launched, most states had not passed legislation to fill gaps in mental health care.
In South Dakota, which has the eighth highest suicide rate among states, health officials said responding to mental health crises in rural counties will be a challenge. So they plan to include volunteer emergency medical services and fire personnel in the emergency response to 988 calls on the ground. More than two-thirds of South Dakotans live in a mental health professional shortage area.
The state has only one professional mobile crisis team that personally responds to emergencies, according to South Dakota Department of Social Services Cabinet Secretary Laurie Gill. The mobile response team is located in South Dakota’s largest city, Sioux Falls, and serves the southeastern corner of the state.
“Some of our communities have virtual mobile crisis teams,” said Janet Kittams, CEO of the Helpline Center, the South Dakota nonprofit that answers the state’s 988 calls. “Some of our communities have co-responder models. Some of our communities will do direct response with law enforcement. So it really varies a lot across the state.”
Sioux Falls is also home to one of the state’s two short-term crisis facilities. The other is more than 300 miles away, in Rapid City. South Dakota also has 11 community mental health centers that assess patients and provide outpatient treatment. These centers also use law enforcement agencies to respond to mental health crises.
A helpline center advisor could direct a 988 call to one of these centers.
“Sometimes, yes, you have to drive several hours to get to a community psychological center, but sometimes you don’t,” Kittams said. “In general, people who live in rural parts of South Dakota understand very well that they may have to go to a resource, because that’s probably true in other aspects of their lives, not just for mental health care, but for other types of care or resources they need.”
Helpline Center reported that its operators de-escalate 80% of calls without deploying a crisis team. But Vibrant Emotional Health, a nonprofit that co-manages the national Lifeline, has projected a fivefold increase in calls for South Dakota in the first year that 988 is in place. Any spike in calls is likely to increase demand on crisis teams.
Vibrant has said that 988 will reach at least an additional 2 million people across the country in its first year. Half of them are expected to come from diverting mental health-related calls from 911 to other crisis centers to 988.
Just next door in South Dakota, Iowa entered the 988 era with a more robust mobile crisis response system — “at least on paper,” said Peggy Huppert, executive director of the Iowa chapter of the National Alliance on Mental Illness. Eighty-seven of the state’s 99 counties have a mobile crisis provider, but most Iowans live in a mental health professional shortage area.
The remaining 12 counties — all rural — rely on law enforcement officers and emergency medical technicians, Huppert said.
“We still have a long way to go with the proper training of all first responders, especially law enforcement officers, because law enforcement is trained to come to a scene and take control of the scene,” she said. “People who are in a behavioral health crisis, who may be psychotic, sometimes they hear voices, they hallucinate, they’re in an altered state. They’re not prone to following commands. That’s where things often go sideways to go. “
Officials at a 988 call center for nine counties in east-central Iowa, operated by CommUnity Crisis Services, said their mobile crisis teams are staffed only by counselors, but that law enforcement agencies can be called if a team determines it is necessary for its safety .
CommUnity Crisis Services has three mobile crisis services providers who arrive in unmarked vehicles.
Adrianne Korbakes, chief operating officer at CommUnity, said the mobile crisis teams are a great option in rural communities where seeking mental health treatment can carry a stigma. And with 988, she said, “you can call or text or chat from the privacy of your own home — no one has to know you have access to services.”
To prepare for these contacts, CommUnity has nearly doubled its staff over the past seven months — expanding from 88 employees in January to 175 in July.
Despite the 988 preparations in Iowa and South Dakota, neither state legislature has funded the system long-term. In the National Suicide Hotline Designation Act of 2020, Congress gave states the authority to cover 988 expenses by adding a surcharge to cell phone service, but most have not done so.
Only 13 states have enacted 988 pieces of legislation, according to the National Alliance on Mental Illness, with varying applications and prescriptions across the continuum of care.
In Iowa, Huppert said, “there’s very much a wait-and-see approach.”
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health policy research organization not affiliated with Kaiser Permanente.
