Taking a Look at 988 Suicide & Crisis Lifeline Implementation One Year After Launch
On July 16, 2022, the federally mandated crisis number, 988, became available to all landline and cell phone users, providing a single three-digit number to access a network of over 200 local and state-funded crisis centers. 988 users who are suicidal or experiencing a behavioral health emergency are routed to the 988 Suicide & Crisis Lifeline (formerly the National Suicide Prevention Lifeline) and connected to a crisis counselor where they may receive crisis counseling, resources and referrals, and in some cases and where available, mobile crisis units may be dispatched. Over half a million lives (528,805) were lost to suicide between 2010 to 2021. In 2021, rates of suicide varied widely across states from 6.2 per 100,000 in D.C. to 32.3 per 100,000 in Wyoming and while a few states saw rates decline from 2010 to 2021, most states saw increases (Appendix Table 1). Nationally, firearms are involved in over half (53%) of all suicides, but the percentage differs considerably from state to state. Concurrent with increased rates of suicide, a KFF/CNN poll from October 2022 finds that 9 in 10 adults in the United States believe there is a mental health crisis.
The federal government made investments in 988’s launch and implementation, but the responsibility for ongoing funding of local call centers is in the hands of state and local governments. The Consolidated Appropriations Act passed in December 2022 included a number of provisions to improve coordination, standardization, and evaluation of 988 and the behavioral health crisis continuum, more broadly. In this brief, we examine 988 implementation using data available through May 2023 from Lifeline, examine state efforts to sustainably fund local 988 crisis call centers, and summarize additional metrics that may be useful for monitoring the implementation and performance of the program. We compare national and state-level Lifeline performance metrics from nearly one year after the launch of 988 (May 2023) to the same month from a year before. The comparison of May 2023 to the same month the year before allows us to account for any seasonal fluctuations in suicide and call volume.
Key takeaways from KFF analysis of Lifeline data include the following:
- Since launch in July 2022, 988 has received almost 5 million contacts, of which nearly 1 million are from the Veteran’s Crisis Line—a part of 988—with the rest consisting of 2.6 million calls, over 740,000 chats, and more than 600,000 texts.
- National answer rates increased alongside surges in outreach volume.
- In-state answer rates vary widely across states—from 55 to 98%—which may reflect state investments in crisis services, as well as length of investment.
- State-level momentum for 988 telecom fees is gaining traction, with legislation in place in six states and two additional states expected to follow suit.
- 988 metrics are available online through Lifeline and sometimes through state or local dashboards, but these data are limited.
What do we know about 988 implementation?
Lifeline’s 988 calling code became nationally available on July 16, 2022, enabling callers to connect with local crisis counselors using the easy-to-remember three-digit number that people can access via phone, text, or chat. When the local crisis call center is unavailable or the wait is too long, callers are redirected to out-of-state Lifeline overflow call centers. Lifeline users can also text 988; historically, text messages have been routed to Lifeline’s backup text/chat centers, but many local call centers are now developing the capacity and infrastructure to respond to text messages. Chat is also available to users and can be accessed through an internet browser on Lifeline’s website. Some crisis call centers still have direct phone numbers, as do crisis centers that are not part of the Lifeline network, and some users may choose to call those numbers instead of 988. Crisis calls to numbers other than 988 may not appear in 988 metrics. National and state-level 988 metrics are publicly available through May 2023. National measures include totals or averages for calls, texts, and chats—including data for outreach volume, answer rates, abandoned calls, average waiting times, and average call length. Lifeline also provides state-level data, but only for calls. Data from the Veterans Crisis Line are not publicly available.
Since launch in July 2022 through May 2023 (the latest available data), 988 has received almost 5 million contacts, of which nearly 1 million are from the Veteran’s Crisis Line—a part of 988—with the rest consisting of 2.6 million calls, over 740,000 chats, and more than 600,000 texts. While data from the Veterans Crisis Line (VCL) are not publicly available, SAMHSA reported approximately one million contacts in the year since launch. Comparing the most recent Lifeline performance data available from May 2023 to a year prior, the combined number of calls, texts, and chats increased by 33%. The number of texts increased more than eight-fold over the same period but remain a small share of overall outreach. However, chat volume has decreased, possibly because text communication is preferred over chat, which is held inside a browser chat window, as opposed to texting via cell phone (Figure 1). Before the launch of 988, Lifeline offered both text and chat messaging, but capacity was only sufficient to handle 56% of text messages and 30% of chats.
The answer rate for 988 increased alongside surges in outreach volume, and people spent less time waiting to speak with a counselor. National answer rates overall (including those answered in-state or by overflow facilities) increased to 93% in May 2023, up from 70% the same month the year before. Despite representing a smaller share of overall contacts, the considerable rise in text and chat answer rates drove overall increases—with text and chat answer rates reaching 98% or higher in May 2023 (up from 46% for chats and 82% for texts). (Figure 2). Further, people who reached out to 988 spent less time waiting on hold for a counselor, as the average wait time for all methods combined decreased from 2 minutes and 20 seconds to 35 seconds.
How does implementation vary by state?
In April-May 2023 the 988 in-state answer rate varied widely across states, ranging from a low of 55-69% in five states including D.C. to a high of 90-98% in fourteen states. Specifically, rates ranged from 55% in Alabama to 98% in Mississippi. An “in-state answer rate” is a measure of the percentage of calls answered within state borders. 988 uses the caller’s area code to route the call to the crisis center closest to that area code. If local centers don’t answer calls, they are redirected to out-of-state overflow facilities, which handle approximately 8% of all calls nationally. If national overflow facility counselors are not familiar with local resources, they may not be able to assist callers with treatment referrals or extra assistance, which can be better provided by local crisis centers. Several factors can affect a state’s in-state answer rate–including how much and how long it invests in its local call centers and broader crisis services.
Sustainable funding is a factor in maintaining improved call response rates at local 988 crisis centers and states have the option to fund 988 similarly to 911, through telecom fees. Although federal investments support 988 nationally, states are responsible for long-term funding of the local 988 crisis call centers, which have historically received minimal funding from the federal government (typically between $2,500-$5,000 annually). Under the National Suicide Hotline Designation Act of 2020, states can collect cell phone fees to help sustainably fund their local 988 call centers 988 legislation authorized states to collect cell phone fees to help sustainably fund 988 and other crisis services. Trust funds and general funds appropriations have been set up by some states to support 988 crisis centers, but it is unclear whether these initiatives will sustainably support crisis centers’ long-term funding needs. Additionally, some states have considered billing Medicaid or other payers for crisis hotlines and other crisis services.
State-level momentum for 988 telecom fees is gaining traction, with Minnesota recently passing telecom legislation and two more states expected to follow suit pending the governor’s signature. So far, six states have enacted legislation to fund crisis services through telecom fees, including California, Colorado, Nevada, Virginia, Washington, and most recently Minnesota. Furthermore, Oregon and Delaware are approaching final legislative approval, having passed 988 telecom fees passed in both chambers and awaiting governor’s signatures. Additionally, three other states have pending telecommunications fee legislation. Early adopters of telecom fees, such as Virginia and Washington, reported collecting between 3.6 to 4.5 million in 988 telecom fees during FY 2021, according to an FCC report.
What data beyond lifeline could help inform implementation and improvement efforts?
Additional state and national crisis center metrics may help inform the 988 implementation and future program improvements. Call volume, wait times, and other metrics from Lifeline provide some insights into accessibility and demand for 988, but they don’t tell the whole story. For example, without additional data, we can’t answer questions such as—
- What conditions or circumstances prompted the 988 outreaches (suicidal ideation, episode of psychosis, substance use disorder, depression, etc.)? Are there increases in calls with imminent suicide risk and are these calls concentrated in particular areas or populations? How often are calls coming from 911 dispatch or other sources (self-referral, friend/family, health care professional etc.)?
- How often are calls resolved over the phone and how did the counselor resolve the call (warm handoff to outpatient care, safety plan)? How often are mobile crisis units dispatched? How often do crisis counselors follow-up with users to confirm safety and connection to additional services?
- What was the user experience with 988 and did the experience or satisfaction vary by race/ethnicity, age, and other characteristics?
Comprehensive metrics could aid policymakers and researchers in evaluating the effectiveness of 988 implementation, identify gaps, and develop targeted interventions or policies to fill them. Table 2 contains metrics compiled from existing sources that may be useful for understanding 988’s implementation.
Some states or crisis call centers already track and display detailed crisis metrics through regularly updated dashboards. These online dashboards display key metrics of crisis call data, refreshed every 24 hours. In Arizona, the Solari Crisis Response Network displays aggregate data for crisis call centers in two regions. Similarly, the University of Utah summarizes Utah’s crisis data in a dashboard and in crisis services annual reports (2021 and 2020). South Dakota’s only crisis line displays detailed aggregate data on a publicly accessible dashboard, including historical data and breakouts by age, race, and gender (Figure 4). Data presented on these dashboards are more detailed than Lifeline data, containing metrics on accessibility, referral source, reason for the call, and some outcomes, but many do not contain historical summaries.
Figure 4: South Dakota’s Crisis Services Dashboard
|SOURCE: https://www.helplinecenter.org/9-8-8/data/, accessed July 2023|
Crisis centers are not required to participate in the Lifeline network, and many do not. Therefore, Lifeline data does not provide a comprehensive picture of all crisis hotline outreach. According to a survey by the National Association of State Mental Health Program Directors Research Institute (NRI), out of the 544 behavioral health crisis centers in the 48 responding states, only about 37% (around 200) are Lifeline call centers. While some states plan to incorporate non-Lifeline centers into the Lifeline network, others prefer maintaining their separate operations.
Lifeline volume increased substantially following 988’s implementation and data reported after implementation suggests that, at the national level, 988 is keeping up with demand in terms of outreach volume, wait times, and answer rates, but there is substantial state variation. Especially in some states without long-term funding strategies, it is unclear whether local Lifeline call centers can maintain their pace as federal funding decreases and demand increases. The National Suicide Hotline Designation Act of 2020 created a path for states to sustainably fund 988 through telecommunications fees, and so far, legislation has been passed in six states. In May, the Biden administration announced an additional $200 million in funding opportunities to assist states in developing 988 infrastructure and related crisis services. While this funding can help with infrastructure and training, it is not a substitute for long-term state funding strategies. In addition to strengthening 988, some states are simultaneously developing and building out their behavioral health crisis continuum to connect those in crisis with additional services like mobile crisis units or crisis stabilization, where appropriate. In March 2023, Lifeline expanded its LGBTQ+ services, enabling 24/7 text and phone access to specialized LGBTQ+ affirming counseling for those under age 25.
Publicly available Lifeline data only capture a small slice of metrics needed to understand implementation, identify gaps, and identify policies and interventions to address shortfalls. Demographic data would allow for the evaluation of 988 from an equity perspective. While not necessarily insurmountable, logistic challenges and privacy concerns may make it difficult to collect this information during all emergency calls.
The Consolidated Appropriations Act, passed in December 2022, included a number of provisions aimed at strengthening and evaluating 988 and the behavioral health crisis continuum. The Act established the Behavioral Health Crisis Coordinating Office within SAMHSA and directed the identification and publication of best practices for the behavioral health crisis response continuum. As part of the Act, various agencies were directed to generate reports evaluating the performance measures and outcomes of the behavioral health crisis continuum, 988, and innovative pilot programs intended to improve 988, with some initial efforts due within a year of CAA enactment. The accessibility, reach, quality, equity, and impact of 988 services and outcomes will be revealed more clearly as 988 metrics and data standards improve and additional data become available.
If you or someone you know is considering suicide, contact the 988 Suicide & Crisis Lifeline at 988
This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.