The 988 Suicide and Crisis Lifeline in the <scp>US</scp>: status of evidence on implementation
Authors: Jonathan Purtle, Michael Lindsey
Journal: World Psychiatry (2025)

In July 2022, "988" became the US dialing code for the Suicide and Crisis Lifeline, which replaced what was, since 2005, the National Suicide Prevention Lifeline (NSPL), reachable via "1-800-273-TALK". The transition from a ten to three-digit dialing code – like others widely known and used in the US – was intended to increase awareness and use of the lifeline. Furthermore, by changing the name and marketing of the lifeline from being narrowly focused on suicide to being explicitly inclusive of mental health crisis more broadly, 988 expanded the target population. Since evaluations of the NSPL suggest that it improved callers' psychological well-being and reduced the incidence of suicide death1, 2, 988 has potential to produce benefits for population mental health in the US. In this piece, written about two years after 988's launch, we provide an overview of extant evidence about 988's implementation. This evidence spans six domains. First is evidence from administrative data about 988 call volume. This increased nationally by about 40% (compared to the previous lifeline) to almost 5 million contacts in the first year after the launch. The call volume increased in every state, but the magnitude of the increase differed dramatically between states (e.g., increase of 74% in Wisconsin versus 8% in Texas)3. One study also documented wide between-state variation in Google searches for 9884, which could reflect variation in the intensity of marketing between states. In general, increases in call volume can be interpreted as a promising finding, given that daily increases in NSPL call volume – prompted by a pop song promoting the lifeline – were independently associated with daily reductions in suicide death2. Future research should explore whether similar associations between call volume and suicide death (as well as other outcomes, such as emergency department use for mental health crisis) persist in the 988 context. Second is evidence about the prevalence and correlates of 988 use. This evidence comes from surveys conducted with nationally representative probability panels about one year after the launch of the lifeline5-8. One of these surveys found that 0.8% (95% CI: 0.5-1.0) of adult respondents had used 988 on behalf of themselves5. However, the proportion was 6% (95% CI: 3.6-8.3) among respondents with "serious" past 30-day psychological distress (Kessler K6 score ≥13), compared to 1% (95% CI: 0.4-1.6) of those with moderate distress and 0.2% (95% CI: 0-0.3) among those with no distress. Another survey of US residents aged ≥13 found that 2% had used 988 and that the proportion was 3% among respondents with a history of suicidality/suicide attempt6. While these studies shed light on the prevalence of 988 use, future work should explore the incidence of this use and the correlates of repeated use among individual callers. Third is evidence related to people's experiences using 988. These data also come from population-based probability surveys, but should be interpreted with caution, given the small sample sizes (i.e., N<50) of respondents. One of these surveys found that, among respondents who had used 988 on behalf of themselves or a loved one, 68% reported receiving "all" (28%) or "some" (40%) of "the help they needed", while 14% selected the response "No, did not receive the help needed"7. Another survey found that only 29% of adults with serious past 30-day psychological distress who used 988 reported being "very likely" (6-7 on a 7-point scale) to use it in the future if they were experiencing suicidality or a mental health crisis5. These data highlight the importance of future research that explores how, and for whom, 988 is or is not satisfying callers' needs and expectations. Fourth is evidence about knowledge about and intention to use 988. About one-year following 988's launch, about half of US adults had heard of 9885. This proportion will inevitably increase as time elapses and people are exposed to more marketing and news about the lifeline. Data indicate, however, that not all people who are aware of 988 have intention to use it if they or a loved one need it in the future. One of the aforementioned surveys found that the percentage of respondents who reported being "very likely" to use 988 in a crisis was lower among those with serious (22%; 95% CI: 18-26) and moderate (21%; 95% CI: 18-23) distress than no distress (26%; 95% CI: 25-28)5. Another of the surveys found that just 35% of adults reported being "highly likely" to use 988 if they or someone they knew "needed help"8. A separate survey found that 26% of respondents had "a great deal of trust" that they would receive the help they needed if they contacted 988 – compared to 37% for contacting 911 (an emergency number for any police, fire or medical help)7. Another of the surveys found that 33% of respondents aged ≥13 reported being "likely" (4-5 on 5-point scale) to use 988 if they were "struggling with [their] mental health", and the proportion was 37% among respondents with a history of suicidality/suicide attempt6. These findings highlight a need for communications research that can inform marketing and messages which foster positive attitudes towards 988 and intention to use it if needed in the future. Fifth is evidence related to 988 financing. Although 988 was created by federal law, states have broad discretion regarding how and the extent to which they fund implementation. Extant data indicate broad between-state heterogeneity in 988 financing. One study found that fiscal year 2022 state per capita expenditures for 988 ranged between $4.73 to $0.30 (mean ± SD: $1.15±1.28)3. Surveys of public system leaders also found wide between-state variation in 988 financial readiness. Consistent with state variation in 988 financing and readiness, between-state variation was documented in the extent to which state legislators promulgated the launch of 988 on social media and mentioned the importance of state financing in its implementation success9. Variations in state 988 financing offer opportunities for natural experimentation and assessing the effects of different financing approaches and levels of investments. Sixth is evidence about the performance of 988 systems. Numerous metrics of state 988 system performance are available in public reports (e.g., https://988lifeline.org/our-network). In general, these data are promising and indicate that federal and state investments in 988 have enhanced the capacity of lifeline systems. For example, in March 2024, the mean 988 wait time across US states was 21 seconds. The mean in-state answer rate – i.e., the percentage of calls from a state fielded in that state, conceptualized as a quality metric – was 85%. This is an improvement from the NSPL era, despite increases is lifeline demand which require greater staffing capacity. Future research should examine associations between changes in these system-level metrics, population mental health outcomes, and disparities therein. 988 has the ability to save lives and improve population mental health, and has demonstrated early evidence of fulfilling its potential. However, like any population-based intervention, these benefits come with potential risks – such as 988 callers having a sub-optimal experience with a counselor that discourages future help-seeking, or being referred to community-based services that they are unable to access. Policy makers and system leaders across the US are making decisions about 988 implementation, and evidence from rigorous research is crucial to informing these decisions.