The Journey Toward 988: A Historical Perspective on Crisis Hotlines in the United States.

This article reviews the historical trajectory of crisis hotlines in the United States from their 1960's inception as 24/7 alternatives to traditional mental health services to becoming "the front door" of the 988 Suicide and Crisis Lifeline in 2022. The Substance Abuse and Mental Health Services Administration's (SAMHSA's) 2001 effort to network, certify, and evaluate crisis hotlines laid the foundation for demonstrating the efficacy of crisis hotlines and their ability to reduce distress and suicidality in people accessing these services. SAMHSA-funded evaluations and the collective leadership of the National Suicide Prevention Lifeline network established evidence-based standards, policies, and practices.

Third-party callers to the national suicide prevention lifeline: Seeking assistance on behalf of people at imminent risk of suicide.

OBJECTIVE: To assist suicidal individuals, people in their social network are often directed to the National Suicide Prevention Lifeline (Lifeline). The study's objective was to provide information on third-party calls made out of concern for another person. METHOD: Reports on 172 third-party calls concerning individuals deemed to be at imminent suicide risk were completed by 30 crisis counselors at six Lifeline crisis centers. RESULTS: Third-party callers were most likely to be calling about a family member or friend and were significantly more likely than persons at risk to be female and middle-aged or older. Counselors were able to collect information about suicide risk, and counselors and third-parties were nearly always able to identify at least one intervention to aid the person at risk. Emergency services were contacted on 58.1 percent of the calls, which represents a somewhat higher rate of emergency services involvement than previously reported on imminent risk calls placed by the person at risk. Characteristics of third-parties and persons-at-risk each predicted emergency service involvement, but counselor characteristics did not. Non-emergency interventions were implemented on 68.6 percent of calls. CONCLUSIONS: Individuals calling the Lifeline when they are worried about someone are provided a range of interventions which can supplement, and at times replace, calling 911.

National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness.

OBJECTIVE: As part of the National Suicide Prevention Lifeline's crisis response system, the Lifeline Crisis Chat Network (LCC) answers chats from hundreds of thousands of at-risk individuals yearly. The study's objective was to assess the effectiveness of these online crisis interventions. METHOD: Data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys completed by LCC chatters from October 2017-June 2018 were analyzed. The relationship of several effectiveness measures with chatter demographics, pre-chat distress, suicidal ideation, and chatters' perceptions of engagement with their counselors was examined using a series of logistic regression analyses. RESULTS: Chatters were significantly and substantially less distressed at the end of the chat intervention than at the beginning. By the end of the chat, two-thirds of suicidal chatters reported that the chat had been helpful, while just under half reported being less suicidal. CONCLUSIONS: Our study offers empirical evidence for the Lifeline's online crisis chat services' effectiveness, but also highlights areas for improvement. This is of critical import in light of the recent designation of 988 as the nationwide number for the Lifeline beginning in 2022, which will increase the Lifeline's prominence in providing suicide prevention and mental health crisis interventions in the United States.

Suicide mortality and related behavior following calls to the Veterans Crisis Line by Veterans Health Administration patients.

OBJECTIVES: To assess outcomes for Veterans Health Administration (VHA) patients following calls to the Veterans Crisis Line (VCL). METHODS: 158,927 VHA patients had an initial VCL call in 2010-2015 with documented identifiers. Multivariable proportional hazards regressions assessed risks of suicide and suicide-related behavior through 12 months. Covariates included age, sex, region, mental health encounters in the prior year, time of day, weekday/weekend status, call outcome, and responder determination of caller risk. RESULTS: Annualized suicide rates per 100,000 within 1, 3, 6, and 12 months were 797, 520, 387, and 298, respectively. Average age was 49.9 (SD = 15.2), 86.5% were male, 68.6% received mental health encounters in the prior year, and 5.9% had calls categorized as at high risk. Adjusting for covariates, suicide risk was greater among male callers and those with calls categorized as at high or moderate risk. CONCLUSIONS: Veterans Crisis Line serves a high-risk population at a critical time. Rates were particularly high within one month and remained substantially elevated through 12 months. Findings have directly informed ongoing efforts to enhance coordination between VCL and VHA to support suicide prevention.

Physical activity, sedentary, and dietary behaviors associated with indicators of mental health and suicide risk.

We used data from the 2017 national Youth Risk Behavior Survey to examine associations between physical activity, sedentary, and healthy dietary behaviors and indicators of mental health, suicidal thoughts, and suicidal attempts among a representative sample of US high school students. Sex-stratified logistic regression was used to separately model each mental health-related outcome on the health-related behaviors, while controlling for race/ethnicity, grade, and body weight status. Significant associations were found between insufficient physical activity, sedentary, and less healthy dietary behaviors and the mental health-related outcomes. Feeling sad and hopeless was associated with not eating breakfast on all 7 days (past week), drinking soda or pop (female only), not meeting the aerobic physical activity guideline (male only), not playing on at least one sports team, and playing video/computer games or using a computer more than two hours (per day). Suicidal thoughts were associated with not eating breakfast on all 7 days, drinking soda or pop, not meeting the aerobic physical activity guideline, and playing video/computer games or using a computer more than two hours per day. Attempted suicide was associated with not eating breakfast on all 7 days, drinking soda or pop, drinking sports drinks, watching television more than two hours per day, and playing video or computer games or using a computer more than two hours per day (male only). While limiting sedentary behaviors and increasing physical activity and healthy dietary behaviors is not a sole solution for improving mental health among adolescents, it could be another possible strategy used in schools to benefit all students.

Long-term impact of the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide mortality, 2006-2015.

BACKGROUND: Comprehensive suicide prevention programs funded through the Garrett Lee Smith Memorial Youth Suicide Prevention Program (GLS) have previously been shown to be associated with lower youth suicide mortality rates 1 year following program implementation. However, longer term effects of GLS have yet to be examined. METHODS: The impact of GLS implementation on youth suicide mortality through 2015 was estimated for U.S. counties initially exposed to state and tribal GLS activities between 2006 and 2009. The analytic approach combined propensity score-based techniques to address potential confounding arising from differences between counties exposed and not exposed to the program along an extensive set of characteristics, including historical suicide rates. RESULTS: Counties exposed to GLS during a single year had youth suicide mortality rates lower than expected and for longer than previously reported following implementation of GLS activities. Youth suicide mortality rates in counties implementing GLS were estimated to be 0.9 per 100,000 youths lower than control counties (p = .029) 1 year after the implementation, and 1.1 per 100,000 youths lower than control counties (p = .010) 2 years after the implementation. Further, persistent implementation during multiple years was associated with larger effects during longer periods. Additionally, among rural counties, the youth suicide rates 2 years after exposure were estimated to be 2.4 per 100,000 youths lower than in the absence of the program (p = .003). There was no significant evidence of a decrease in youth suicide rates three or more years after the GLS activities were discontinued. CONCLUSIONS: The effects of GLS comprehensive suicide prevention program were found to be stronger and longer lasting than previously reported, particularly in rural counties. In the face of well-documented increases in national suicide prevention rates, these results support the widespread and persistent implementation of comprehensive, community-based youth suicide prevention programs.

Examining the Unanticipated Adverse Consequences of Youth Suicide Prevention Strategies: A Literature Review with Recommendations for Prevention Programs.

OBJECTIVE: Youth suicide is a public health problem in the United States. Suicide prevention programs have been shown to be beneficial; however, knowledge of unanticipated adverse consequences of programs is limited. The objective of this review is to present what is known about these consequences so informed decisions and appropriate planning can be made prior to implementation of suicide prevention interventions. METHOD: A narrative but systematic review was conducted assessing what is known about adverse consequences utilizing a comprehensive keyword search of EBSCO and PubMed databases. Study populations beyond youth were included. RESULTS: Unanticipated adverse consequences of suicide prevention interventions were included in 22 publications. Consequences occur at three levels: at the level of the youth, those who identify or intervene with at-risk youth, and at the system level. While rare, unanticipated adverse consequences include an increase in maladaptive coping and a decrease in help-seeking among program targets, overburden or increased suicide ideation among program implementers, and inadequate systemic preparedness. CONCLUSIONS: Overall, the benefits of youth suicide prevention outweigh the unanticipated adverse consequences. Nevertheless, these results may be utilized for informed decision-making regarding suicide prevention programming, and to ensure appropriate infrastructure is in place prior to prevention efforts.

Comparing the Effectiveness of Brief Versus In-Depth Gatekeeper Training on Behavioral Outcomes for Trainees.

BACKGROUND: A common suicide prevention strategy is training gatekeepers to identify at-risk individuals and refer them to services. AIMS: The study aimed to examine whether differences in training outcomes were observed for brief versus in-depth gatekeeper trainings for trainees from varied professional settings while controlling for differences in trainee characteristics and community context. METHOD: Trainees' identification and referral behavior 3 months after gatekeeper training was compared with a sample of respondents matched on individual- and community-level variables using propensity score-based techniques. The value was estimated, in terms of additional identification and associated costs, of adopting in-depth training. RESULTS: A higher proportion of trainees who participated in in-depth trainings from K-12 and community settings identified at-risk youth, and a higher proportion of in-depth trainees from mental health settings referred youth to services compared with participants of brief trainings from the same setting and with similar characteristics. The effect of training type on outcomes varied by professional role and community context. LIMITATIONS: Self-report measures were used to assess outcomes. Similar measures are used in other studies; their validity has not been conclusively established. CONCLUSION: Findings suggest certain individuals may benefit from in-depth training more than others, which favors targeting this intervention to particular gatekeepers.

RISING SUN: Prioritized Outcomes for Suicide Prevention in the Arctic.

The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

Predictive utility of an emergency department decision support tool in patients with active suicidal ideation.

Emergency department (ED) clinicians routinely decide the disposition of patients with suicidal ideation, with potential consequences for patient safety, liability, and system costs and resources. An expert consensus panel recently created a 6-item decision support tool for patients with passive or active suicidal ideation. Individuals scoring a 0 (exhibiting none of the tool's 6 items) are considered "lower risk" and suitable for discharge, while those with non-0 scores are considered "elevated risk" and should receive further evaluation. The current study tested the predictive utility of this tool using existing data from the Emergency Department Safety Assessment and Follow-up Evaluation. ED patients with active suicide ideation (n = 1368) were followed for 12 months after an index visit using telephone assessment and medical chart review. About 1 in 5 patients had attempted suicide during follow-up. Because of the frequency of serious warning signs and risk factors in this population, only three patients met tool criteria for "lower risk" at baseline. The tool had perfect sensitivity, but exceptionally low specificity, in predicting suicidal behavior within 6 weeks and 12 months. In logistic regression analyses, several tool items were significantly associated with suicidal behavior within 6 weeks (suicide plan, past attempt) and 12 months (suicide plan, past attempt, suicide intent, significant mental health condition, irritability/agitation/aggression). Although the tool did not perform well as a binary instrument among those with active suicidal ideation, having a suicide plan identified almost all attempters while suicide plan and past attempt identified over four-fifths of near-term attempts. (PsycINFO Database Record

The Relationship Between Perceived Unmet Mental Health Care Needs and Suicidal Ideation and Attempt.

This study utilizes data from the National Survey of Drug Use and Health (NSDUH) to analyze the relationship between perceived unmet mental health care needs and suicidal ideation and attempt. Estimates from multivariable logistic regression models suggest that individuals who report perceived unmet mental health care needs have higher probability of experiencing suicidal ideation and attempt. Perceived unmet mental health care need has an important association with suicidal ideation and attempt, and efforts aimed at improving access to care are needed to address this issue.

National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults.

OBJECTIVE: This study examined national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. METHOD: We examined restricted data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied. RESULTS: Among US young adults during 2009 to 2015, the 12-month prevalence of suicidal ideation increased from 6.1% to 8.3%, the 12-month prevalence of suicide plan increased from 2.0% to 2.7%, and 12-month prevalence of suicide attempt increased from 1.1% to 1.6%. After adjusting for personal factors and changes in residing county's population characteristics, we found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plan among young adults overall, and an upward trend in suicide attempt among those without major depressive episodes (MDE). Among young adults with MDE, the prevalence of suicide attempt remained high and unchanged. During 2009 to 2015, trends in receipt of mental health care remained unchanged among most suicidal young adults and declined slightly among uninsured suicidal young adults. The annual average prevalence of receipt of mental health care was 36.2% among suicidal young adults. CONCLUSION: During 2009 to 2015, suicidal ideation, suicide plan, and suicide attempt increased among young adults overall, but receipt of mental health care among suicidal young adults did not increase. Our results suggest that effective efforts are needed for suicide prevention and promotion of mental health care among young adults.

An Economic Evaluation of the Garrett Lee Smith Memorial Suicide Prevention Program.

For more than a decade, the Garrett Lee Smith Youth Suicide Prevention Program has provided funding for community-based suicide prevention programs to states, tribes, and colleges across the United States. Recent studies provided evidence of the program's effectiveness in reducing suicide mortality and suicide attempts among youth. This study compares the cost of implementing the program with the estimated savings resulting from avoided hospitalization and emergency department visits associated with the averted suicide attempts. The findings suggest that the cost of implementing multifaceted community-based suicide prevention strategies may be more than outweighed by savings in the health sector.

Follow-up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers' Perceptions of Care.

Continuity of care for suicidal individuals engaged with a variety of health and mental health care systems has become a national priority, and crisis hotlines are increasingly playing a part in the risk management and continuum of care for these individuals. The current study evaluated a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow-up care to suicidal callers. Data were obtained from 550 callers followed by 41 crisis counselors from 6 centers. Two main data sources provided the information for the current study: a self-report counselor questionnaire on the follow-up activities completed on each clinical follow-up call and a telephone interview with follow-up clients, providing data on their perceptions of the follow-up intervention's effectiveness. The majority of interviewed follow-up clients reported that the intervention stopped them from killing themselves (79.6%) and kept them safe (90.6%). Counselor activities, such as discussing distractors, social contacts to call for help, and reasons for dying, and individual factors, such as baseline suicide risk, were associated with callers' perceptions of the impact of the intervention on their suicide risk. Our findings provide evidence that follow-up calls to suicidal individuals can reduce the perceived risk of future suicidal behavior.

Self-Reported Reasons for Not Receiving Mental Health Treatment in Adults With Serious Suicidal Thoughts.

OBJECTIVE: This study examined self-reported reasons for not receiving mental health treatment among adults with past-year serious suicidal thoughts and their sociodemographic characteristics associated with these reasons. METHODS: Using the 2008-2013 National Surveys on Drug Use and Health, we examined 8,400 respondents aged 18 years or older who had past-year serious thoughts of suicide and did not receive mental health treatment that year. Logistic regression analyses were conducted to estimate the associations between sociodemographic characteristics and self-reported reasons for not receiving mental health treatment among these suicidal adults. RESULTS: Among adults with serious suicidal thoughts who did not receive mental health treatment in the past year, three-fourths did not feel the need for treatment. Of the one-fourth of those who felt the need for treatment, the main reason for not receiving treatment was financial (58.4%), followed by logistical reasons such as not knowing where to go (36.1%). A greater proportion of suicidal adults than nonsuicidal adults perceived more than 1 barrier to treatment (43.8% vs 34.3%). Among suicidal adults who did not receive mental health treatment that year, the odds of not feeling the need for mental health treatment were higher in men (adjusted odds ratio [AOR] = 1.68; 95% CI, 1.42-1.99), adults aged 50 years or older (AOR = 3.02; 95% CI, 2.02-4.51), racial and ethnic minorities (AORs = 1.59-2.13), publicly insured (AOR = 1.54; 95% CI, 1.14-2.07), and nonmetropolitan residents (AOR = 1.50; 95% CI, 1.20-1.88). CONCLUSIONS: Most suicidal adults did not feel the need for mental health treatment. Of those who felt the need, multiple barriers were identified. A multifaceted approach to address these barriers is needed to promote receipt of mental health treatment among this vulnerable population.

Service Use in the Month and Year Prior to Suicide Among Adults Enrolled in Ohio Medicaid.

OBJECTIVES: The purpose of this study was to inform suicide prevention efforts by estimating the incidence of suicide among adult Medicaid enrollees and describing clinical profiles and service utilization patterns among decedents. METHODS: Death certificate data for adults (N=1,338) ages 19 to 65 who died by suicide between January 1, 2008, and December 31, 2013, were linked with Ohio Medicaid data. RESULTS: The suicide rate was 18.9 deaths per 100,000 Ohio Medicaid enrollees. Most decedents (83%) made a general medical or mental health visit within one year of suicide, with 50% doing so within 30 days and 27% within one week before death. In the year before suicide, the median number of visits was 16, indicating a subgroup with intensive service utilization. Decedents whose visits were proximal to suicide (within 30 days) rather than distal (31-365 days) were more likely to have individual and co-occurring behavioral and general medical conditions and to be Medicaid eligible through disability. In the year before suicide, most visits (79%) were outpatient general medical visits. Also in the year before suicide, decedents with serious psychiatric disorders were more likely than those without such disorders to make only mental health visits, and those with chronic general medical conditions were more likely than those without such conditions to make only general medical visits. CONCLUSIONS: Medicaid enrollment designates a "virtual boundary" around a subpopulation of health care consumers relevant to national suicide prevention efforts. Findings highlight the potential of using Medicaid data to identify individuals at risk of suicide for screening, prevention, and intervention.

Prevalence and Mental Health Treatment of Suicidal Ideation and Behavior Among College Students Aged 18-25 Years and Their Non-College-Attending Peers in the United States.

OBJECTIVE: College students have been the focus of many studies on suicidal ideation with or without suicidal behavior. Little attention has been given to their non-college-attending peers on these issues. We examined the 12-month prevalence and mental health treatment of suicidal ideation with or without suicidal behavior among college students aged 18-25 years and their non-college-attending peers in the United States. METHODS: We assessed data from 135,300 persons aged 18-25 years who participated in the 2008-2013 National Surveys on Drug Use and Health. Descriptive analyses and multivariate logistic regression models were applied. RESULTS: Compared with full-time college students, high school students, those not enrolled in a school or college, and part-time college students were more likely to attempt suicide with a plan (model-adjusted prevalence = 0.67% vs 1.09%, 1.06%, and 1.07%, respectively). The mental health treatment rate among full-time college students with suicidal ideation with or without suicidal behavior was similar to the rates among the other 3 counterparts. The effects of race/ethnicity and serious mental illness on receipt of mental health treatment were significantly larger among those who did not perceive unmet treatment need than among those who perceived unmet treatment need (P = .019 and P = .001, respectively). CONCLUSIONS: Compared to full-time college students, non-college-attending young adults and part-time college students were at higher risk for attempting suicide with a plan. Suicide prevention and intervention strategies should emphasize increasing access to mental health treatment among both college students with suicidal ideation with or without suicidal behavior and their non-college-attending peers (particularly among minorities and those who seem to be at low risk because they are without serious mental illness and report no need for mental health treatment).

Estimating the rates of deaths by suicide among adults who attempt suicide in the United States.

BACKGROUND: In 2012, over 1.3 million U.S. adults reported that they attempted suicide in the past year, and 39,426 adults died by suicide. This study estimated national suicide case fatality rates among adult suicide attempters (fatal and nonfatal cases) and examined how they varied by sociodemographic characteristics. METHODS: We pooled data on deaths by suicide (n = 147,427, fatal cases in the U.S.) from the 2008-2011 U S. mortality files and data on suicide attempters who survived (n = 2000 nonfatal cases) from the 2008-2012 National Surveys on Drug Use and Health. Descriptive analyses and multivariable logistic regression models were applied. RESULTS: Among adult suicide attempters in the U.S., the overall 12-month suicide case fatality rate was 3.2% (95% confidence interval (CI) = 2.9%-3.5%). It varied significantly by sociodemographic factors. For those aged 45 or older, the adjusted suicide case fatality rate was higher among men (7.6%) than among women (2.6%) (suicide case fatality rate ratio (SCFRR) = 3.0, 95% CI = 1.83-4.79), was higher among non-Hispanic whites (7.9%) than among non-white minorities (0.8-2.5%) (SCFRRs = 3.2-9.9), and was higher among those with less than high school education (16.0%) than among college graduates (1.8%) (SCFRR = 8.8, 95% CI = 3.83-20.16). Across male and female attempters, being aged 45 or older and non-Hispanic white and having less than secondary school were at a higher risk for death by suicide. CONCLUSIONS: Focusing on these demographic characteristics can help identify suicide attempters at higher risk for death by suicide, inform clinical assessments, and improve suicide prevention and intervention efforts by increasing high-risk suicide attempters' access to mental health treatment.