America’s mental health helpline network expands, but rural areas still face care shortages
The National Suicide Prevention Lifeline’s 988 phone number, launched July 16, was designed as a universal mental health support tool for callers anytime, anywhere.
But the United States is a patchwork of resources for crisis aid, so what comes next isn’t universal. The level of assistance 988 callers receive depends on their postal code.
In particular, rural Americans, who die by suicide at a much higher rate than urban residents, often struggle to access mental health services. While 988 may connect them to a call center close to home, they could end up being directed to distant resources.
The new system is supposed to offer people an alternative to 911, but callers in rural areas experiencing a mental health crisis may still be greeted by law enforcement rather than mental health specialists.
More than 150 million people in the United States — most from rural or partially 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 care providers – usually psychiatrists – to serve the population.
The Biden administration has distributed about $105 million to states to help boost local crisis call center staffing for the new 988 system. But states are responsible for filling any gaps in the continuum of care on which callers count if they need more than a phone conversation. The states also assume the bulk of the responsibility for staffing and funding their 988 call centers once federal funding runs out.
The federal Substance Abuse and Mental Health Services Administration, which runs the existing lifeline 800-273-8255 on which 988 is expanding, said a state that launches a successful 988 program will ensure callers have a professional mental health to talk to, a mobile crisis team to respond to, and a place to go — such as a short-term crisis stabilization residential 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 relieve pressure on emergency rooms.
These goals may not play out in the same way in all states or communities.
If a call center doesn’t have a mobile crisis team to send, “you don’t have stabilization, so 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 has developed model 988 legislation for states that emphasizes the need for consistent services, regardless of caller location.
For the new appeal system to be cohesive, “you really need that full continuum of care,” Hepburn said. “We don’t expect it to be available now. The expectation is, he says, that your condition will eventually get you there.
But when 988 launched, most states had not passed legislation to address mental health care gaps.
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. They therefore plan to integrate volunteer emergency medical services and fire personnel into the emergency response to the 988 calls to the field. More than two-thirds of South Dakotans live in an area with a shortage of mental health professionals.
The state has only one professional mobile crisis team that responds to emergencies in person, according to Laurie Gill, cabinet secretary for the South Dakota Department of Human Services. 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 Helpline Center, the South Dakota nonprofit that will answer the state’s 988 calls. “Some of our communities have co-responder models. Some of our communities will respond directly to law enforcement. So it really varies a lot from state to state.
Sioux Falls is also home to one of two short-term crisis facilities in the state. The other is over 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 helpline counselor could direct a 988 caller to one of these centers.
“Sometimes, yes, you’ll have to drive a few hours to get to a community mental health center, but sometimes you won’t,” Kittams said. “In general, people who live in rural South Dakota understand very well that they are potentially going to 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 that they need.
The helpline reported that its operators defused 80% of calls without deploying a crisis team. But Vibrant Emotional Health, a nonprofit that co-manages the national lifeline, projected a five-fold increase in calls for South Dakota in the first year of 988 implementation. calls will likely increase the demand for crisis teams.
Vibrant said 988 will reach at least 2 million more people nationwide in its first year. Half of them are expected to go through the diversion of mental health-related calls from 911 and other crisis centers to 988.
Right next 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, Huppert said.
“We still have a long way to go to properly train all first responders, especially law enforcement, as law enforcement is trained to get to the scene and take control of the scene,” she said. “People who are in behavioral health crisis, who are maybe psychotic, sometimes they hear voices, they hallucinate, they are in an altered state. They are not inclined to obey orders. This is where things often go wrong.
Officials at a 988 call center for nine counties in east-central Iowa operated by Community Crisis Services said their mobile crisis teams would be staffed only by counselors, but that the forces of the order could be called if a team determines it is necessary for their 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 be stigmatized. And with 988, she says, “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, from 88 employees in January to 175 in July.
Despite 988 preparations in Iowa and South Dakota, neither state legislature funded the system long term. In the National Suicide Hotline Designation Act of 2020, Congress gave states the power to cover 988 expenses by adding a surcharge to cell phone service, but most did not.
Only 13 states have enacted 988 laws, according to the National Alliance on Mental Illness, with varying applications and prescriptions across the continuum of care.
In Iowa, Huppert said, “there’s really a wait-and-see approach.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polls, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.
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