America’s mental health hotline is expanding, but rural areas still face a shortage of care

The National Suicide Prevention Lifeline 988, which launched on July 16, is designed as a universal mental health support tool for callers anytime, anywhere.

But the US is a patchwork of crisis relief resources, so what follows is not universal. The level of support that 988 callers receive depends on their postcode.

In particular, rural Americans, who die by suicide at a much higher rate than urban residents, often have trouble accessing mental health services. Although 988 may connect them to a call center close to home, they may find themselves directed to distant resources.

The new system is supposed to give people an alternative to 911, but rural callers experiencing a mental health crisis may still be met by law enforcement officers rather than mental health professionals.

More than 150 million people in the U.S. — 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. That means their communities don’t have enough mental health providers — usually psychiatrists — to serve the population.

The Biden administration allocated about $105 million to states to help increase staffing of local crisis centers for the new 988 system. But states are responsible for filling any gaps in the continuity of care that callers rely on if they need more than a phone call. States also assume most of the responsibility for staffing and funding their 988 call centers after federal funding runs out.

The federal Substance Abuse and Mental Health Services Administration, which operates the existing 800-273-8255 helpline that 988 is expanding, said a state that launches a successful 988 program will ensure that callers have a mental health professional with whom to talk to, a mobile crisis team to respond to them, and a place to go—like a short-term residential crisis stabilization facility—that offers diagnosis and treatment. The federal agency also intends for 988 to reduce reliance on law enforcement, expand access to mental health care and ease pressure on emergency rooms.

These goals may not be met equally in all countries or communities.

If the call center doesn’t have a mobile crisis team to send, “you don’t have the stabilization, then you actually 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 Directors of Mental Health Programs. The group developed Model 988 legislation for states that emphasizes the need for consistent service regardless of the caller’s location.

For the new call system to be consistent, “you really need that full continuum of care,” Hepburn said. “The expectation is not that it’s available now. The expectation is, he said, that your state will eventually take you there.

But when 988 launched, most states had not enacted legislation to close 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 areas will be challenging. So they plan to include EMS volunteers and fire department personnel in the emergency response to 988 calls on site. More than two-thirds of South Dakota residents live in an area with a shortage of mental health professionals.

The state has only one professional mobile crisis team that responds in person to emergencies, according to South Dakota Department of Human Services Cabinet Secretary Lori Gill. The mobile response team is located in South Dakota’s largest city, Sioux Falls, and serves the southeast 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 will answer 988 calls in the state. “Some of our communities have collaborative response models. Some of our communities will be responding directly to law enforcement. So it really varies quite a bit across the state.”

Sioux Falls is also home to one of two short-term crisis facilities in the state. 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 to respond to mental health crises.

A help center advisor can direct a 988 caller to one of these centers.

“Sometimes, yes, you’ll have to drive several hours to get to a community mental health center, but sometimes not,” Kittams said. “Generally speaking, people who live in rural South Dakota understand very well that they will potentially have to drive 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.’

The helpline center reported that its operators de-escalate 80% of calls without having a crisis team on hand. But Vibrant Emotional Health, a nonprofit that co-administers the national helpline, predicts a fivefold increase in calls to South Dakota in the first year 988 is available. Any spike in calls is likely to increase demand for crisis teams.

Vibrant said 988 will reach at least 2 million more people nationwide in its first year. Half of those are expected to come by diverting mental health calls from 911 and other crisis centers to 988.

Next door to 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 an area with a shortage of mental health professionals.

The remaining 12 counties — all rural — rely on law enforcement and emergency medical technicians, Hooper said.

“We still have a long way to go with proper training of all first responders, especially law enforcement, as law enforcement is trained to come on scene and take control of the scene,” she said. “People who are in a behavioral health crisis, who are maybe psychotic, sometimes they hear voices, they hallucinate, they’re in an altered state. They do not tend to obey commands. This is where things often go wrong.

Officials at the nine-county 988 call center in east-central Iowa, run by CommUnity Crisis Services, said their mobile crisis teams will be staffed only by counselors, but that law enforcement could be called if the team decides it’s necessary. is necessary for his safety.

CommUnity Crisis Services has three mobile crisis service providers who arrive in unmarked vehicles.

Adrianne Korbakes, chief operating officer at CommUnity, said 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, text or chat from the privacy of your own home — no one has to know you’re accessing services.”

To prepare for these contacts, CommUnity has nearly doubled its staff in the past seven months—expanding from 88 employees in January to 175 in July.

Despite 988 preparations in Iowa and South Dakota, neither state’s legislatures have funded the system long term. In the National Suicide Hotline Act of 2020, Congress gave states the authority to cover 988 costs by adding a surcharge to cell phone service, but most have not done so.

According to the National Alliance on Mental Illness, only 13 states have enacted legislation since 1988 with various applications and prescriptions for continuing treatment.

In Iowa, Huppert said, “there’s a lot of a wait-and-see approach.”

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