A Critical Window To Decriminalize Mental Health
Mental health in the US is in crisis. Suicide rates have increased over the past decade. Pediatric and adult emergency department visits for suicide attempts have substantially increased since the onset of the COVID-19 pandemic. Less than half of adults with mental illness are receiving treatment, and the demand for inpatient psychiatric care consistently and significantly exceeds supply.
This July, the US model for responding to individuals experiencing a mental health crisis is scheduled for a much-needed change. The 988 number is a three-digit, national mental health crisis hotline that was mandated by the federal government in October 2020 with an official nationwide start date on July 16, 2022. This hotline builds on the infrastructure of the National Suicide Prevention Lifeline but with a broader directive: to provide 24/7 phone or text support for anyone experiencing a mental health crisis or in need of suicide prevention services. The National Suicide Prevention Lifeline currently receives four million calls or texts per year. As of July, these calls—as well as calls from regional and local crisis centers, and calls to 911 that meet certain criteria—will be redirected to 988. As a result, even moderate growth in call volume could result in a more-than-sixfold increase to 24 million callers or texters per year by 2026.
Decriminalization Of Mental Health
The 988 hotline holds incredible promise toward decriminalizing the response to mental health emergencies. Currently, if an individual is experiencing a mental health crisis, they, their caregivers, and bystanders have few options beyond calling 911. As a result, roughly one in 10 individuals with mental health disorders have interacted with law enforcement prior to receiving psychiatric care, and 10 percent of police calls are for mental health emergencies. When police arrive, if they determine an acute safety risk, they transport the individual in crisis for further psychiatric assessment, most commonly at a medical emergency department. This almost always takes place in a police vehicle, many times in handcuffs, a scenario that contradicts central tenets of trauma-informed mental health care. In the worst-case scenario, confrontation with police results in injury or death. Adverse outcomes during response to mental health emergencies are more than 10-fold more likely for individuals with mental health conditions than for individuals without, and are disproportionately experienced by people of color. This consequence was tragically highlighted by the death of Walter Wallace, Jr., who was killed by police while experiencing a mental health emergency in October 2021.
Ideally, the new 988 number would activate an entirely different cascade of events. An individual in crisis, their family member, or even a bystander will be able to immediately reach a trained crisis counselor who can provide phone-based triage, support, and local resources. If needed, the counselor can activate a mobile mental health crisis team that will arrive on site to de-escalate; provide brief therapeutic interventions; either refer for close outpatient follow up or transport the individual for further psychiatric evaluation; and even offer food, drink, and hygiene supplies.
'States must transition to 988 as a universal number'
Rather than forcing families to call 911 for any type of help—regardless of criminal activity—the 988 line will allow individuals to access mental health crisis support without involving law enforcement. This approach can empower families to self-advocate for the right level of mental health care—including avoiding unnecessary medical emergency department visits, which are not typically designed to handle mental health crises and can further traumatize individuals and their families—and to initiate psychiatric assessment and treatment sooner. 911 dispatchers will also be able to re-route calls to 988 when appropriate, allowing law enforcement personnel to spend more time on their primary role of ensuring public safety. Finally, the 988 number will help offer a middle option for individuals who need rapid linkage to care, including rapid psychiatric evaluation and initiation of treatment, but do not yet meet criteria for crisis. This is a crucial service given current difficulties in accessing timely, in-network outpatient mental health care.
Challenges In Implementation
However, the potential for 988 to improve mental health care will fall short if our infrastructure is not prepared. Currently, only four states have passed legislation to fund 988 call centers, in spite of the rollout occurring in less than five months. Callers will not be able to reach well-trained, locally knowledgeable mental health counselors without state resources, and 911 dispatchers will not be able to divert 911 calls to 988 if there aren’t enough call centers.
More concerningly, in spite of $3 billion in American Rescue Plan funding directed toward mental health infrastructure and more than $280 million in 988-specific Substance Abuse and Mental Health Services Administration block grants, many local mobile crisis programs have not been augmented to meet the demand that the 988 hotline will bring. Almost no mobile crisis teams in the country are available 24/7; very few can reliably arrive to an individual in crisis in less than one hour; and most do not include a clinician, such as an emergency medical technician, able to administer medication—let alone the ability to do all three. Without this infrastructure in place, 988 calls in which an individual is acutely at risk of harming themselves or others will be re-routed back to 911. If 988 calls increase without the appropriate resources to respond, there may be a paradoxical increase in law enforcement involvement for transport as more individuals are identified as being in acute danger.
Next Steps
To prevent these unintended consequences, federal, state, and local governments need to mobilize individuals living with mental health conditions, community members, health care workers, and law enforcement to inform the last stages of 988 planning and to advocate for pressing needs, first among them securing adequate funding. While Medicaid agencies could provide some support, such as reimbursements for mobile crisis services, nontraditional funding mechanisms could help robustly build up the care continuum. For instance, 911 funding frequently comes from landline fees despite the fact that cellular service accounts for more than 80 percent of total telephone spending. New modes of funding could help ensure that mobile mental health crisis teams are able to develop equitable, trauma-informed systems to care for the increased volume of mental health concerns that 988 calls will identify.
Finally, health care leaders need to be prepared to evaluate the impact of the 988 hotline so that they can quickly adapt if the proposed benefits are not being realized. Close monitoring of emergency service dispatch records will help to determine whether law enforcement involvement in non-criminal mental health cases is decreasing. Emergency department and inpatient data can help determine if an increased demand for services is resulting in increased patient boarding or delays in accessing the continuum of mental health care. Most importantly, obtaining feedback from individuals who use the 988 hotline and their families will allow us to understand if this new system is serving them.
Inadequate preparation for the 988 rollout has huge implications for public trust. If calling or texting 988 results in law enforcement being dispatched to the scene, will this resource be used again by families in need? If families are directed to the same stressed mental health system where their loved ones are already unable to access care, will they reach out again?
If communities do not have the resources and infrastructure to help patients—or worse, if calling 988 leads to increased criminal justice system involvement—the hotline will fall short of its promise. Between now and July 16, there is a critical window to ensure its efficacy and equity for individuals needing mental health services and their communities. We need to make the most of it.
Comments