988 Suicide Lifeline in Place, but Access to Crisis Care Falls Short

Megan Brooks

July 19, 2022

Half of US counties have no access to a suicide intervention team, including those with the highest suicide rates, a timely new analysis shows.

As of July 16, Americans experiencing a mental health crisis can call the federally mandated 988 national suicide lifeline to be connected to services and counselors.

"Authorizing 988 provides needed support for behavioral health crises, but local access to crisis care will be required to realize the full potential of these benefits," investigators from the Yale School of Public Health, New Haven, Connecticut, write.

"In terms of whether access will improve in the years ahead, I'm cautiously hopeful," Helen Newton, PhD, MPH, told Medscape Medical News.

The study was published online July 15 in JAMA Network Open.

Historically Underfunded

Drawing on responses to the annual Substance Abuse and Mental Health Services Administration (SAMHSA) survey of public and private healthcare facilities, the researchers assessed county-level access to crisis intervention teams (CITs) in 2015 and 2020.

The study included data on 10,430 facilities in 2015 and 10,591 facilities in 2020, representing 72% and 75% of all facilities that provided mental health treatment services in the 50 states and Washington, DC, in 2015 and 2020.

While most of the US population (88%) had access to a CIT, half of the counties had no facility that offered CIT services. There was little change in the percentage of facilities that had CIT services from 2015 to 2020 (49% and 48%, respectively).

Although the net number of counties with access to a CIT did not change, about 9% of counties lost access, and, separately, 9% gained access in 2020.

"This suggests there may be opportunities to increase public funding or technical support in centers in danger of losing CIT access to prevent these closures," the investigators write.

As with other mental health treatment services, access to CITs remains inequitable.

Compared with counties with CIT services, those without these services tend to have larger populations of older and uninsured residents. They are also more likely to be in rural areas that have the highest suicide rates.

Counties in states that expanded Medicaid were more likely to have CITs.

Newton noted that crisis care has been "historically underfunded." She said 988 provides needed support for behavioral health crisis care and is important because of the financing opportunities that it makes available.

"The designation of 988 as a three-digit emergency number itself creates a financing opportunity: states can now pass legislation to add a tax to individual phone bills, like they already do for 911, to finance the services provided by 988," she explained.

"Additionally, the designation of 988 provides opportunities for federal and state grants to support implementation. For example, the federal government awarded $15 million to 20 state Medicaid agencies in December 2021 to support planning the development community-based mobile crisis intervention services," said Newton.

Bending the Curve

In an invited commentary, Roy H. Perlis, MD, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, says making the 988 national suicide hotline available is an effort to ensure a single point of entry for people in crisis and to begin to "bend the curve on suicide."

Perlis notes that with a public health challenge such as suicide, there is a temptation to engage in "magical thinking about new interventions, biomarkers, or machine learning prediction strategies that will solve our health system's structural problems.

"Such efforts are necessary and important," Perls writes, "but represent an investment in the future ― and even under the most optimistic scenarios, breakthroughs are unlikely to obviate the pressing need to improve access to care. For now, a key part of the solution is low-tech: resources."

Starting in 2021, SAMHSA set aside block grants to states to support evidence-based crisis care, including mobile crisis units. "If these investments catalyze further ones, there is reason to be hopeful that availability of crisis teams and downstream resources will increase," Perlis writes.

"The work by Newton and colleagues more broadly provides a reminder that identifying someone at high risk is only the first step in a complex chain of processes that need to go smoothly to address that risk. Truly bending the suicide curve will require sustained attention and investment, attending not just to the front door to care, but to everything that comes after," Perlis adds.

Support for the study was provided by the National Institute of Mental Health and the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships. Perlis has received personal fees from Psy Therapeutics for SAB service, personal fees from Genomind for SAB service, personal fees from Burrage Capital for SAB service, personal fees from Vault Health for SAB service, and personal fees from Circular Genomics for SAB service outside the submitted work.

JAMA Netw Open. Published online July 15, 2022. Full text, Commentary

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