Taking a Look at 988 Suicide & Crisis Lifeline Implementation

Note: This brief was updated on March 2 to clarify the number of states identified in the legend of Figure 3.

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. Nearly half a million lives (480,622) were lost to suicide between 2010 to 2020 and an additional 47,646 lives were lost in 2021, reflecting a recent rise in suicide rates and 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. Recent legislation, passed as a part of the Consolidated Appropriations Act 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 December 2022 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. Key findings include the following:

  • Outreach to 988 increased after implementation in mid-July, then steadied until December, when it increased again. Text volume increased more than 700% compared to the year prior but remains a smaller share of overall outreach.
  • National answer rates increased alongside surges in outreach volume.
  • In-state answer rates vary widely across states—from 51 to 98%—which may reflect state investments in crisis services, as well as length of investment. To date, five states have chosen to enact legislation for the 988 telecommunication fees that are intended to sustainably fund local crisis centers.
  • 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. 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. Users can also text 988, but most texts go to Lifeline text/chat centers as many local call centers do not currently support texting. 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 December 2022. National measures include totals or averages for call, text, 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, including how many calls are routed, received, answered, abandoned, sent to backup centers, and wait times. Data from the Veterans Crisis Line are not publicly available. In this analysis, we compare national and state-level Lifeline performance metrics from nearly 6 months after the launch of 988 (December 2022) to the same month from a year before (December 2021). The comparison of December 2022 to the same month the year before allows us to account for any seasonal fluctuations in suicide and call volume.

988 outreach increased after its implementation in mid-July, then steadied until December, when it increased again. Comparing December 2022 to a year prior, the combined number of calls, texts, and chats increased by 43%. Over the same period, the number of texts increased more than eight-fold, but still remain a small share of overall outreach. Conversely, chat volume decreased slightly, 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. Since launch, Lifeline has received over 2.1 million contacts—consisting of over 1.43 million calls, over 416,000 chats, and more than 281,000 texts.

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 91% in December 2022, up from 64% 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 96% or higher in December 2022 (up from 24% for chats and 52% 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 52 seconds to 44 seconds.

How is 988 doing at the state level?

In December 2022 the 988 in-state answer rate varies widely across states, ranging from a low of 51-69% in seven states to a high of 90-98% in twelve states and D.C. Specifically rates ranged from 51% in Alabama to 98% in Rhode Island and 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. Calls that are not answered locally are routed to an out-of-state overflow facility or are abandoned by their caller. Nationally, about 10% of calls are transferred to out-of-state overflow facilities and 11% are abandoned by the caller. If 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 from 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.

As states debate their FY 2024 budgets, long-term funding of local 988 crisis call centers may become an issue since only five states have chosen to enact legislation for the 988 telecommunication fees that are intended to sustainably fund local crisis call centers. Although federal investments have assisted with the implementation of 988, ongoing funding for local crisis call centers relies heavily on local and state funds, as local crisis call centers historically receive 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 sustainably fund their local 988 call centers– but only five states have enacted legislation to do so (California, Colorado, Nevada, Virginia, and Washington). Four other states have pending telecommunications fee legislation, and a number of states have proposed but struck down similar legislation. 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.

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 can aid policymakers and researchers in evaluating the effectiveness of 988 implementation, identify gaps, and develop targeted interventions or policies to fill them. Table 1 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). 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 they do not contain historical summaries (Figure 4).

Figure 4: Utah’s State Crisis Services Dashboard

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 outreach. According to a 2021 survey of behavioral health crisis call centers, there were 510 behavioral health crisis centers operating in the responding 32 states, but only 167 or 33% are lifeline call centers. According to the survey, some states are encouraging behavioral health crisis call centers to become Lifeline crisis centers, whereas other states do not plan to take this action.

Looking Ahead

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 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, but so far, legislation has only been enacted in five states. In addition to 988 implementation, 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.

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 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 establishes 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. 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.


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