Crisis response in Texas youth impacted by Hurricane Harvey: A difference-in-differences analysis.

BACKGROUND: Hurricane Harvey was the second costliest storm to impact the U.S. More research is needed to understand the mental health consequences of these extreme events in children and adolescents extending beyond the acute recovery period. METHODS: Daily anonymized Crisis Text Line (CTL) conversations were used to understand patterns in crisis responses for youth one year before and after Harvey's landfall. A quasi-experimental difference-in-differences analysis compared changes in texts for stress/anxiety, depression, thoughts of suicide, and self-harm following Harvey between exposed and unexposed youth in Texas. RESULTS: CTL users with Texas-based area codes (N = 23,016) were compriesd largely of youth who self-identified as female (78.1 %), 14-17 year old (50.4 %), white (38.9 %), and LGBTQ+ (51.2 %). We observed parallel increases in crisis texts for depression and thoughts of suicide in most months following Harvey among exposed and unexposed youth. However, non-impacted youth had significantly larger increases in texts for depression up to three months post-Harvey and thoughts of suicide one year after Harvey compared to directly impacted communities. LIMITATIONS: Sample size was restricted to texters who completed the post-conversation demographics survey, who may fundamentally differ from those who declined to respond. Harvey exposure was determined using texter area code and county-level disaster declarations, limiting our ability to guarantee individual-level exposure. CONCLUSIONS: Texas youth traditionally considered unexposed experienced nearly identical increases in concerns of depression and thoughts of suicide to those directly exposed. Findings suggest spillover effects (e.g., economic concerns, media exposure) may contribute to statewide impacts on youth mental health after natural disasters.

A machine learning approach to identifying suicide risk among text-based crisis counseling encounters.

Introduction: With the increasing utilization of text-based suicide crisis counseling, new means of identifying at risk clients must be explored. Natural language processing (NLP) holds promise for evaluating the content of crisis counseling; here we use a data-driven approach to evaluate NLP methods in identifying client suicide risk. Methods: De-identified crisis counseling data from a regional text-based crisis encounter and mobile tipline application were used to evaluate two modeling approaches in classifying client suicide risk levels. A manual evaluation of model errors and system behavior was conducted. Results: The neural model outperformed a term frequency-inverse document frequency (tf-idf) model in the false-negative rate. While 75% of the neural model's false negative encounters had some discussion of suicidality, 62.5% saw a resolution of the client's initial concerns. Similarly, the neural model detected signals of suicidality in 60.6% of false-positive encounters. Discussion: The neural model demonstrated greater sensitivity in the detection of client suicide risk. A manual assessment of errors and model performance reflected these same findings, detecting higher levels of risk in many of the false-positive encounters and lower levels of risk in many of the false negatives. NLP-based models can detect the suicide risk of text-based crisis encounters from the encounter's content.

The Use of Crisis Services Following the Mass School Shooting in Uvalde, Texas: Quasi-Experimental Event Study.

BACKGROUND: Mass shootings result in widespread psychological trauma for survivors and members of the affected community. However, less is known about the broader effects of indirect exposure (eg, media) to mass shootings. Crisis lines offer a unique opportunity to examine real-time data on the widespread psychological effects of mass shootings. OBJECTIVE: Crisis Text Line is a not-for-profit company that provides 24/7 confidential SMS text message-based mental health support and crisis intervention service. This study examines changes in the volume and composition of firearm-related conversations at Crisis Text Line before and after the mass school shooting at Robb Elementary School on May 24, 2022, in Uvalde, Texas. METHODS: A quasi-experimental event study design was used to compare the actual volume of firearm-related conversations received by Crisis Text Line post shooting to forecasted firearm conversation volume under the counterfactual scenario that a shooting had not occurred. Conversations related to firearms were identified among all conversations using keyword searches. Firearm conversation volume was predicted using a seasonal autoregressive integrated moving average model trained on the 3 months of data leading up to the shooting. Additionally, proportions of issue tags (topics coded post conversation by volunteer crisis counselors at Crisis Text Line after the exchange) were compared in the 4 days before (n=251) and after (n=417) the shooting to assess changes in conversation characteristics. The 4-day window was chosen to reflect the number of days conversation volume remained above forecasted levels. RESULTS: There was a significant increase in the number of conversations mentioning firearms following the shooting, with the largest spike (compared to forecasted numbers) occurring the day after the shooting (n=159) on May 25, 2022. By May 28, the volume reverted to within the 95% CI of the forecasted volume (n=77). Within firearm conversations, "grief" issue tags showed a significant increase in proportion in the week following the shooting, while "isolation/loneliness," "relationships," and "suicide" issue tags showed a significant decrease in proportions the week following the shooting. CONCLUSIONS: The results suggest that the Uvalde school shooting may have contributed to an increase in demand for crisis services, above what would be expected given historical trends. Additionally, we found that these firearm-related crises conversations immediately post event are more likely to be related to grief and less likely to be related to suicide, loneliness, and relationships. Our findings provide some of the first data showing the real-time repercussions for the broader population exposed to school shooting events. This work adds to a growing evidence base documenting and measuring the rippling effects of mass shootings outside of those directly impacted.

Examining Hurricane Ida's Impact on Mental Health: Results From a Quasi-Experimental Analysis.

Limited research has evaluated the mental health effects during compounding disasters (e.g., a hurricane occurring during a pandemic), and few studies have examined post-disaster mental health with alternative data sources like crisis text lines. This study examined changes in crisis help-seeking for individuals in Louisiana, USA, before and after Hurricane Ida (2021), a storm that co-occurred during the COVID-19 pandemic. An interrupted time series analysis and difference-in-difference analysis for single and multiple group comparisons were used to examine pre-and post-changes in crisis text volume (i.e., any crisis text, substance use, thoughts of suicide, stress/anxiety, and bereavement) among help-seeking individuals in communities that received US Federal Emergency Management Agency individual and public assistance following a presidential disaster declaration. Results showed a significant increase in crisis texts for any reason, thoughts of suicide, stress/anxiety, and bereavement in the four-week, three-month, and four-month post-impact period. Findings highlight the need for more mental health support for residents directly impacted by disasters like Hurricane Ida.

Crisis Response and Suicidal Behaviors of Essential Workers and Children of Essential Workers During the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has put unprecedented stress on essential workers and their children. Limited cross-sectional research has found increases in mental health conditions from workload, reduced income, and isolation among essential workers. Less research has been conducted on children of essential workers. We examined trends in the crisis response of essential workers and their children from April 2020 through August 2021. METHODS: We investigated the impact during 3 periods of the pandemic on workers and their children using anonymized data from the Crisis Text Line on crisis help-seeking texts for thoughts of suicide or active suicidal ideation (desire, intent, capability, time frame), abuse (emotional, physical, sexual, unspecified), anxiety/stress, grief, depression, isolation, bullying, eating or body image, gender/sexual identity, self-harm, and substance use. We used generalized estimating equations to study the longitudinal change in crisis response across the later stages of the pandemic using adjusted odds ratios (aORs) for worker status and crisis outcomes. RESULTS: Results demonstrated higher odds of crisis outcomes for thoughts of suicide (aOR = 1.06; 95% CI, 1.00-1.12) and suicide capability (aOR = 1.14; 95% CI, 1.02-1.27) among essential workers than among nonessential workers. Children of essential workers had higher odds of substance use than children of nonessential workers (aOR = 1.33; 95% CI, 1.08-1.65), particularly for Indigenous American children (aOR = 2.76; 95% CI, 1.35-5.36). Essential workers (aOR = 1.17; 95% CI, 1.07-1.27) and their children (aOR = 1.18; 95% CI, 1.07-1.30) had higher odds of grief than nonessential workers and their children. CONCLUSION: Essential workers and their children had elevated crisis outcomes. Immediate and low-cost psychologically supportive interventions are needed to mitigate the mental health impacts of the COVID-19 pandemic on these populations.

Individuals who text crisis text line: Key characteristics and opportunities for suicide prevention.

OBJECTIVE: Text-based crisis services are increasingly prominent, with inclusion in the national 988 crisis number launching in 2022. Yet little is known about who uses them. This study seeks to understand the population served by Crisis Text Line (CTL), the largest crisis text service in the United States. METHODS: Secondary data analysis was conducted on de-identified Crisis Counselor reports, texter post-conversation survey responses, and anonymized text conversation data from 85,877 texters who contacted CTL during a 12-month period. We examined Crisis Counselor's ratings of suicide ideation severity, texters' reports of race, gender, sexual orientation, recent mental health symptoms, and additional sources of help, and logs of frequency of contact. RESULTS: 76% of texters were under 25. 79% were female. 48% identified as other than heterosexual/straight. 64% had only one conversation. 79% were above the clinical cutoff for depression and 80% for anxiety, while 23% had thoughts of suicide. 23% received help from a doctor or therapist, and 28% received help only from CTL. CONCLUSIONS: CTL reaches a highly distressed, young, mostly female population, including typically underserved minorities and a substantial percentage of individuals who do not receive help elsewhere. These findings support the decision to include texting in the forthcoming national 988 implementation.

What twitter can tell us about user experiences of crisis text lines: A qualitative study.

Mental health problems are the leading cause of disability worldwide. Despite the prevalence and cost of mental illness, there are insufficient health services to meet this demand. Crisis hotlines have a number of advantages for addressing mental health challenges and reducing barriers to support. Mental health crisis services have recently expanded beyond telephone hotlines to include other communication modalities such as chat and text messaging services, largely in response to the increased use of mobile phones and text messaging for social communication. Despite the high uptake of crisis text line services (CTLs) and rising mental health problems worldwide, CTLs remain understudied. The current study aimed to address an urgent need to evaluate user experiences with text-based crisis services. This study explored user experiences of CTLs by accessing users' publicly available Twitter posts that describe personal use and experience with CTLs. Data were qualitatively analyzed using thematic analysis. Six main themes were identified from 776 tweets: (1) approval of CTLs, (2) helpful counselling, (3) invalidating or unhelpful counselling, (4) problems with how the service is delivered, (5) features of the service that facilitate accessibility, and (6) indication that the service suits multiple needs. Overall, results provide evidence for the value of text-based crisis support, as many users reported positive experiences of effective counselling that provided helpful coping skills, de-escalation, and reduction of harm. Results also identified areas for improvement, particularly ensuring more timely service delivery and effective communication of empathy. Text-based services may require targeted training to apply methods that effectively convey empathy in this medium. Moving forward, CTL services will require systematic attention in the clinical research literature to ensure their continued success and popularity among users.

Quasi-experimental evaluation of text-based crisis patterns in youth following Hurricane Florence in the Carolinas, 2018.

IMPORTANCE: Crisis text lines have proven to be an effective and low-cost means for delivering texting-based mental health support to youth. Yet there has been limited research examining the use of these services in capturing the psychological impact on youth affected by a weather-related disaster. OBJECTIVE: This ecologic study examined changes in help-seeking behavior for adolescents and young adults in North and South Carolina, USA, before and after Hurricane Florence (2018). DESIGN AND MAIN OUTCOMES: A retrospective, interrupted time-series design was used to examine pre- and post-hurricane changes in crisis text volume among youth help seekers in the Carolinas for the following outcomes: (1) text for any reason; (2) stress & anxiety; (3) depression; and (4) suicidal thoughts. RESULTS: Results showed an immediate and sustained increase in crisis texts for stress/anxiety and suicidal thoughts in the six weeks following Florence. Overall, an immediate 15% increase in crisis texts for anxiety/stress (SE = 0.05, p = .005) and a 17% increase in suicidal thoughts (SE = 0.07, p = .02) occurred during the week of the storm. Text volume for anxiety/stress increased 17% (SE = 0.08, p = .005) and 23% for suicidal ideation (SE = 0.08, p = .01) in the 6-week post-hurricane period. Finally, forecast models revealed observed text volume for all mental health outcomes was higher than expected in the 6 weeks post-Florence. CONCLUSIONS AND RELEVANCE: A low-cost, crisis texting platform provided 24/7 mental health support available to young people in the Carolinas impacted by Hurricane Florence. These findings highlight a new application for text-based crisis support services to address the mental health consequences in youth following a weather-related disaster, as well as the potential for these types of crisis platforms to measure situational awareness in impacted communities.

Crisis text patterns in youth following the release of 13 Reasons Why Season 2 and celebrity suicides: A case study of 2018.

There is considerable debate in the public arena and among the professional mental health community around the media's role in increasing suicide risk following exposure to suicide-themed media in youth. A recent example involves the concerning reaction to the release of Netflix's controversial hit teen-suicide drama 13 Reasons Why. This follow-up study examined the association between the release of 13 Reasons Why Season 2 (13RW2), which coincided with two celebrity suicides, and national trends in crisis-related text conversations. We implemented an interrupted time series design to examine changes in daily counts of crisis texts aggregated at the national level following two events: (1) the release of 13RW2 and (2) celebrity suicide deaths of Anthony Bourdain and Kate Spade. We also performed a sub-analysis of suicide-related crisis conversations following each event. Crisis conversation volume was 42% higher after the release of 13RW2 for 6 of the 18 days of the study period, while crisis text usage was 51% higher for 9 out of the 18 days after the publicized celebrity suicide deaths. Both the release of 13RW2 and the celebrity suicides in the summer of 2018 were followed by an abrupt, but transient rise in crisis help-seeking among adolescents. Media outlets should consider pairing suicide-themed content with crisis support services as a core best practice to reduce the risk of population-level adverse reactions to suicide portrayals or coverage.

Crisis Text Line use following the release of Netflix series 13 Reasons Why Season 1: Time-series analysis of help-seeking behavior in youth.

The availability of near real-time data from Crisis Text Line (CTL) and other technology-based platforms on crisis events provides an opportunity for targeted interventions prior to serious mental health outcomes (e.g., suicide, self-harm). This study examined the association between the release of the popular Netflix series 13 Reasons Why (13RW) and CTL usage in a national sample of youth in the US. We implemented interrupted time-series, autoregressive integrated moving average (ARIMA) modeling to examine this association at a daily scale. We observed a significant but momentary rise in CTL conversation volume following the release of 13RW on April 5 and 6, 2017 followed by a significant reduction (12.7%) in conversation volume for the overall study period. This reduction in call volume was sustained for 49 days and is the most sustained reduction in conversation volume in the 365 day dataset. This unexpected trough in conversation volume is concerning in light of elevated search engine volume for terms indicating an increase in suicidal thoughts in the days following the release of the show (Ayers et al., 2017). CTL was featured by the show as a resource for viewers in the recently released Season 2, and our results highlight the reasoning and need for such promotion. Future work should explore whether the promotion of CTL in Season 2 positively impacted conversation volume, as there is a clear need to harness the power of these digital technologies to detect population-based trends in mental health and expand the reach of life saving services.

Crisis support-seeking behavior and temperature in the United States: Is there an association in young adults and adolescents?

BACKGROUND: Mounting evidence demonstrates the relationship between high temperatures and adverse mental health outcomes. Yet, no study has examined the influence of temperature on crisis support-seeking behavior among youth in large urban areas. METHODS: Crisis Text Line (CTL) is a text messaging service that provides crisis interventions for support-seeking individuals for a range of mental-health outcomes in the United States. We applied a distributed lag non-linear modeling technique to assess the short-term impacts of daily maximum and minimum temperature on crisis-related events in four metropolitan locations in the USA. RESULTS: There were multiple positive associations in three of the four study locations that demonstrate crisis help-seeking behavior increased during anomalously warm conditions. CONCLUSIONS: This study suggests that there is a significant association between high minimum or maximum temperatures and crisis help-seeking behaviors in young adults and adolescents in urban areas in the United States.