Expert Commentary

988 and suicide prevention hotlines: A research roundup

For journalists covering the launch of 988, it helps to be familiar with the research on suicide prevention hotlines. We have complied several peer-reviewed research studies on the topic, including text and online chats.

Photo by John Tuesday on Unsplash

Suicide prevention hotlines are implemented in many countries and are considered an important part of suicide prevention efforts. In the U.S., the National Suicide Prevention Lifeline network of crisis centers not only serve people who are in a mental health crisis, but also connect individuals with resources in their communities.

On July 16, the 988 Suicide & Crisis Lifeline launched in the United States, building on the existing National Suicide Prevention Lifeline and switching from the 10 digit number, 800-273-8255. The 800 number remains available and will be routed to 988.

The three-digit number was created after the National Hotline Designation Act was signed into law in 2020, in response to calls by lawmakers and advocates and a collaboration between the U.S. Department of Health and Human Services, the Federal Communications Commission and the U.S. Department of Veterans Affairs.

One of the main reasons advocates have been calling for a three-digit number is because when we are in a crisis, “our cognitive recall is not as present,” explains Amelia Lehto, chief of staff at the American Association of Suicidology. “So, remembering 800-273-8255 or even 800-273-TALK [can be] challenging, and the idea was to simplify it.”

The 24-hour 988 Suicide and Crisis Lifeline is funded by Substance Abuse and Mental Health Services Administration, which is part of the National Institutes of Health, and is administered by Vibrant Emotional Health, a nonprofit organization in the U.S. that has run the national Lifeline since it was established in 2005.

The Lifeline received 46,000 calls in its first year. In 2021 it received 3.6 million calls, chats and texts. In total, the Lifeline received 23,044,100 calls from 2005 through 2021. The number is expected to double within the first year after the 988 transition, according to the FCC.

The Lifeline includes more than 200 independently operated and funded local call centers, including 38 chat and text centers and three Spanish language centers. The centers are funded by local and state sources and SAMHSA.

“I think one of the greater benefits of the 988 crisis Lifeline is that they are a national network of local centers, who are familiar with their local resources,” says Lehto.

But it’s not clear how quickly the local centers can ramp up their capacity. A recent New York Times data analysis finds that 18% of about 1 million calls to Lifeline centers in the first half of this year were not answered. Other news stories have also started to document the need for more funding at local crisis centers. In December SAMHSA announced a $282 million investment to transition the National Suicide Prevention Lifeline to 988 to help strengthen the exiting Lifeline infrastructure and build staffing in local centers.

Suicide is among the leading causes of death in the U.S. and around the world, making it a serious public health problem. In the U.S., it was the 12th leading cause of death and the second leading cause of death for people ages 10-14 and 25-34 that year in 2020, according to the Centers for Disease Control and Prevention.

Nearly 46,000 people died by suicide in the U.S. in 2020 and 1.2 million people attempted suicide but didn’t die, according to the CDC.

Worldwide, 703,000 people died by suicide in 2019, according to the latest data from the World Health Organization.

For journalists covering the launch of 988, it helps to be familiar with the research on suicide prevention lifelines. We have complied several peer-reviewed research studies on the topic, including text and online chats. The studies focus on the U.S. and many are based on surveys of crisis counselors and/or callers.

Reporting guides recommend including information about suicide hotlines when reporting on the topic. You can download and use this infograph.

Research roundup

Third‐Party Callers to the National Suicide Prevention Lifeline: Seeking Assistance on Behalf of People at Imminent Risk of Suicide
Madelyn Gould; et al. Suicide & Life-Threatening Behavior, February 2022.

The study: Researchers wanted to gain a better understanding of the types of calls that were made to the National Suicide Prevention Lifeline by people who were concerned for another person. They analyzed 172 such calls based on questionnaires completed by 30 crisis counselors in six Lifeline crisis centers between December 2016 and October 2018. Counselors handled on average 7.5 suicide calls per seek, with a range from 1 to 20 calls.

Key findings: Third‐party callers were most likely to be calling about a family member or friend. They were also significantly more likely to be female and middle‐aged or older, compared with the person at risk. Counselors were able to identify at least one intervention to help the person at risk. In 58.1% of the calls, emergency services were contacted. The most common source of the callers’ information was face‐to‐face contact with the person at risk, and other modes including interactions via text messaging, phone calls and social media.

Key takeaway: Negative help‐seeking attitudes are greatest among individuals with the greatest mental health needs, the authors note. “Given the reluctance of many suicidal individuals to seek help for themselves, suicide prevention initiatives often encourage people in the social networks of at‐risk individuals to seek help on their behalf,” they write. “In contrast to a third‐party calling 911, which only dispatches an emergency service — frequently involving the police — calling the Lifeline yields alternative and adjunctive interventions.”

Suicide Mortality and Related Behavior Following Calls to the Veterans Crisis Line by Veterans Health Administration Patients
Claire Hannemann; et al. Suicide & Life-Threatening Behavior, October 2020.

The study: The Veterans Crisis Line, which was established in 2007, serves veterans and is staffed by Veterans Affairs clinical staff. (The Veterans Crisis Line is part of the national Lifeline and veterans can reach it by dialing 988 and then pressing 1.) Researchers analyzed 158,927 calls to the Veterans Crisis Line between 2010 and 2015 to assess the rates of suicide deaths and suicide attempts following calls. The study was not designed to assess the crisis line’s effectiveness.

Key findings: The Veterans Crisis Line serves a high-risk Veterans Health Administration patient subpopulation, with particularly high rates of suicide deaths and attempts in the first month after the initial call to the crisis line. While suicide rates decreased over the 12 months after the initial call, the rates remained elevated compared with the overall VHA patient population. The suicide rate in the first month following an initial documented call was 797 per 100,000, and it was 298 per 100,000 at 12 months. In comparison, the overall suicide rate for VHA patient population was 36 per 100,000 in 2016, the authors note. Men were twice as likely as women to die by suicide within 12 months after the initial call.

Key takeaway: “This study documents substantially elevated risk of suicide and suicide-related behavior among VHA patients who call the Veterans Crisis Line,” the authors write. “Study findings may also inform work to enhance services for callers to non-VA crisis lines, and they confirm the importance of integrating crisis line services within healthcare systems.”

Individuals Who Text Crisis Text Line: Key Characteristics and Opportunities for Suicide Prevention
Anthony Pisani; et al. Suicide & Life-Threatening Behavior, June 2022.

The study: Researchers explored the demographics of the population that uses Crisis Text Line, the largest crisis text service in the U.S. Established in 2013, it is a nonprofit based in New York, unaffiliated with 988. The findings are based on anonymous reports from crisis counselors and surveys from 85,877 texters who contacted Crisis Text Line between October 2017 and October 2018. More than half of the texters were white; 13% were Hispanic; 8.2% were Black; 3.5% were Asian; and 1.1% were American Indian/Alaska native.

Key findings: Results show 76% of texters were under 25 years old and 66% were between 14 and 24 years old; 79% were female; 48% identified as other than heterosexual; and 23% had thoughts of suicide. Meanwhile, 23% of texters reported having received assistance from a doctor or a therapist when in crisis and 28% had not asked for help from any other source, a situation that was even worse for younger texters, the authors note.

Key takeaway: “[Crisis Text Line] reaches a highly distressed, young, mostly female population, including typically underserved minorities and a substantial percentage of individuals who do not receive help elsewhere,” the authors write. “Providing crisis support for males, who account for the vast majority of suicide deaths remains a challenge for the field, including for text-based crisis interventions.”

Related study: “Crisis text-line interventions: Evaluation of texters’ perceptions of effectiveness,” by Madelyn Gould; et al., published in Suicide & Life-Threatening Behavior in June 2022, assesses the perception of texters as to the effectiveness of the Crisis Text Line interventions. It finds 90% of suicidal texters found the conversations helpful and nearly half reported being less suicidal by the end of the text-based conversation.

National Suicide Prevention Lifeline Crisis Chat Interventions: Evaluation of Chatters’ Perceptions of Effectiveness
Madelyn Gould; et al. Suicide & Life-Threatening Behavior, December 2021.

The study: Researchers assesses the effectiveness of the Lifeline Crisis Chat, which was established in 2013 and is the online typed chat feature of the National Suicide Prevention Lifeline, answering 231,335 chats in 2020. The authors analyzed data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys from October 2017 to June 2018. About 65% of the chat users were female and more than 70% of were younger than 24 years. Nearly half said feeling depressed was the main reason for which they reached out. Almost 84% of callers said they had suicidal thoughts in the past 24 hours or in the past few days.

Key findings: By the end of the chat, two-thirds of the people who reached out via online chat and were suicidal reported that the correspondence had been helpful and 45% reported being less suicidal, while 30% said they felt the same as when they began the chat and 12% said they were more suicidal.

Key takeaway: “For a single‐session chat intervention to achieve a reduction in suicidality in nearly half of chatters can be considered a significant accomplishment,” the authors write. “While a single chat session could not be expected to eradicate suicide risk permanently, any reduction in risk at a moment of crisis for these individuals could open a window of opportunity for further help‐seeking and for engagement in additional interventions that could have a more sustained impact.”

Increases in Demand for Crisis and Other Suicide Prevention Services After a Celebrity Suicide
Rajeev Ramchand; et al. Psychiatric Services, April 2019.

The study: Researchers examined data on increases in suicides, help and information seeking, and capacity of crisis centers within 30 days after the death of actor and comedian Robin Williams on Aug. 11, 2014. Data included call volume to the National Suicide Prevention Lifeline and the number of visits to two suicide prevention websites — the Suicide Prevention Resource Center and Suicide Awareness Voices of Education.

Key findings: Before Aug. 11, in 2012, 2013 and 2014, daily suicide deaths in the U.S. averaged between 113 and 117. For the 30 days after Aug. 11, 2014, the count increased to 142. The number of calls to the Lifeline increased by 300% to 12,972 calls on August 12 and decreased afterward, but answered calls decreased from 71% before August 11 to 57% on August 12, indicating a gap in capacity, the authors note. Visits to both websites also increased dramatically on August 12 and decreased on the following days.

Key takeaway: “As a critical component of crisis mental health services in the United States, suicide prevention hotlines need to develop contingency plans to accommodate anticipated increases in demand, including for at least two days after a celebrity suicide,” the authors write.

Association of Logic’s Hip Hop Song “1-800-273-8255” with Lifeline Calls and Suicides in the United States: Interrupted Time Series Analysis
Thomas Niederkrotenthaler; et al. The BMJ, December 2021.

The study: Researchers examined the changes in daily call volumes to the National Suicide Prevention Lifeline after the release of hip-hop artist Logic’s song ‘1-800-273-8255’ in April 2017. They analyzed tweets that mentioned Logic’s song from March 2017 to April 2018. Their main interests in call volumes were around three events: the song’s release, and Logic’s performance of the song at the MTV Video Music Awards in August 2017 and Grammy Awards in January 2018. They also obtained total number of calls to the Lifeline from January 2010 to December 2018.

Key findings: The number of calls to the Lifeline increased by 6.9% — 9,915 additional calls — during the 34 days when public attention to the song was substantial, the authors report, compared with average call volumes. There was also some evidence of reduction in suicides, by 5.5%. “Although the reduction in suicides was small, this finding shows that the song did not result in harmful effects on suicide occurrence, which would have been indicated by an increase in suicides,” the authors write.

Key takeaway: “The effectiveness of the song on calls to a helpline is a novel finding,” the authors write. “The results show that it is possible to promote help-seeking for suicidal crises in the absence of negative news, and indicate that suicides could potentially be reduced with prevention focused campaigning, such as Logic’s song.”

Related study: “Public Awareness of the National Suicide Prevention Lifeline Following the Release of a Hip-Hop Song,” by Trevor Torgerson; et al., published in BMJ Evidence-Based Medicine in July 2021, finds Google searchers for “Suicide Hotline” and Twitter engagement with Lifeline’s account @800273talk increased following the release of Logic’s song ‘1-800-273-8255.’

Follow-up with Callers to the National Suicide Prevention Lifeline: Evaluation of Callers’ Perceptions of Care
Madelyn Gould; et al. Suicide & Life-Threatening Behavior, March 2017.

The study: Researchers evaluated the effectiveness of a national initiative to have crisis centers in the National Suicide Prevention Lifeline network provide follow-up care to callers who were suicidal. Data was pulled from questionnaires filled out by 41 crisis counselors in six centers and telephone interviews with 550 clients.

Key findings: Nearly 80% of the interviewed clients reported that the intervention stopped them from killing themselves and 91% said it kept them safe. Individuals at higher risk of suicide at the time of their calls to the Lifeline perceived the follow-up intervention to be more valuable — so did those who had lower levels of education or had been homeless — than those at lower suicide risk, the authors note.

Key takeaway: “Our findings add to the mounting evidence that follow-up is a key intervention to enhance the continued safety of individuals at risk of suicide,” the authors write. “Our findings lay the groundwork for later initiatives to have crisis hotlines provide follow-up to at-risk individuals following inpatient psychiatric hospitalization or discharge from emergency departments, when enhanced continuity of care can be equally lifesaving.”

National Suicide Prevention Lifeline: Enhancing Mental Health Care for Suicidal Individuals and Other People in Crisis
Madelyn Gould, Jimmie Munfakh, Marjorie Kleinman, and Alison Lake. Suicide & Life-Threatening Behavior, February 2012.

The study: Researchers explored the extent to which callers to the Lifeline are referred to longer-term mental health services. The study is based on phone interview with 376 suicidal and 278 non-suicidal callers to the National Suicide Prevention Lifeline between January 2006 and December 2007. Sixteen centers in the Lifeline network from 14 states across the U.S. participated in the study.

Key findings: Nearly 83% of the callers reported having received mental health treatment at some point in their lives and 46% were in treatment at the time of their call. However, only 35% of callers referred to mental health resources followed through with the referral. “It is particularly alarming that a third of callers reported a lack of trust or negative experience with mental health providers as their reason for not accessing mental health care after the call,” the authors write. Barriers to accessing mental health services included denying the severity of one’s mental health problem, financial problems and not having health insurance

Key takeaway: The caller’s perception of mental health problems was the most prevalent barrier to using mental health services and was cited more often than other barriers such as stigma and financial barriers. “A further function of hotline counseling may be to address callers’ attitudinal and perceptual barriers to formal service use and to help callers to overcome them,” the authors write.

An Evaluation of Crisis Hotline Outcomes Part 2: Suicidal Callers
Madelyn Gould, John Kalafat, Jimmie Lou Harris Munfakh, and Marjorie Kleinman. Suicide & Life-Threatening Behavior, December 2010.

The study: In a follow-up study on nonsuicidal callers, researchers evaluated the effectiveness of telephone crisis hotlines in changing the callers’ suicide state from the start to end of the call in eight centers in the U.S., and again within three weeks of their calls, between March 2003 and July 2004, before the launch for the National Suicide Prevention Lifeline. They assessed 1,085 suicide calls; 35% of the callers participated in the follow-up assessment.

Key findings: Researchers found significant decreases in suicidality during the telephone session, and continuing decreases in hopelessness and psychological pain in the following weeks. However, 43.2% of the callers continued to express suicidal ideation a few weeks after the initial call and nearly 3% had made a suicide attempt after their call, the authors note.

Key takeaway: “Our study provides empirical evidence that seriously suicidal individuals are reaching out to telephone crisis services,” the authors write. “Our findings also suggest that follow-up outreach strategies may need to be heightened, particularly for suicidal callers with a history of suicide attempts, who were significantly over-represented among those who reattempted shortly after their call to the center.”

Related study:An Evaluation of Crisis Hotline Outcomes Part 1: Nonsuicidal Crisis Callers,” published in the same issue by the same researchers, finds significant decreases in callers’ crisis states and hopelessness during the course of the telephone session. The crisis state and hopelessness continued to decrease in the following weeks.

Additional studies

The Effectiveness of Crisis Line Services: A Systematic Review,” by Adam Hoffberg, Kelly Stearns-Yoder and Lisa Brenner, published in Frontiers in Public Health in January 2020, finds that high-quality evidence demonstrating crisis line effectiveness is limited, but overall, the results provide support for such services. “However, such support is largely from uncontrolled studies indicating the positive effect of crisis line calls on immediate proximal outcome measures (e.g., changes in distress over the course of the crisis line call) and short-term distal effects. Many studies evaluating distal effects after the crisis service suffered from substantial dropout, thereby increasing the risk of bias interpreting findings,” the authors write.

Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: Evaluation of Caller Risk Profiles and Interventions Implemented,” by Madelyn Gould; et al., published in Suicide & Life-Threatening Behavior in August 2015, offers four different profiles for callers who are at imminent risk of suicide: High-risk calls with a moderate-to-high rate of engagement with the crisis line counselor; relatively low-risk calls with high engagement; moderate-to-high-risk calls with a moderate amount of missing information due to modest engagement; and very high-risk calls with a large amount of missing information due to low engagement. “Our findings provide a first step toward an empirical formulation of imminent risk warning signs and recommended interventions,” the authors write.

Systematic Review of Research and Interventions With Frequent Callers to Suicide Prevention Helplines and Crisis Centers,” by Brian Mishara, Louis-Philippe Côté, and Luc Dargis, published in Crisis in January 2022, reviews 27 studies to identify characteristics of frequent callers and compiles recommendations about how best to help them.

Mental Health Concerns During the COVID-19 Pandemic As Revealed by Helpline Calls,” by Marius Brülhart, Valentin Klotzbücher, Rafael Lalive, and Stephanie Reich, published in Nature on November 2021, finds a 35% increase in calls in the first six week after the initial COVID-19 outbreak, mainly driven by fear, loneliness and concerns about physical health. “Relationship issues, economic problems, violence and suicidal ideation, however, were less prevalent than before the pandemic,” the authors write.

Safety Planning on Crisis Lines: Feasibility, Acceptability, and Perceived Helpfulness of a Brief Intervention to Mitigate Future Suicide Risk,” by Christa Labouliere, Barbara Stanley, Alison Lake, and Madelyn Gould, published in Suicide & Life-Threatening Behavior in February 2020, explores the effectiveness of the use of an established intervention called Safety Planning Intervention to help manage suicidal crises on hotlines. While found feasible and helpful, the authors note that some centers may have difficulty implementing it due to factors like high call volumes.

Implementation and Early Utilization of a Suicide Hotline for Veterans,” by Kerry Knox, Janet Kemp, Richard McKeon, and Ira R. Katz, published in the American Journal of Public Health in March 2012, is one of the first reports on the Veterans Crisis Line. “These are the first data to demonstrate that a population consisting primarily of men is willing to call a suicide hotline and accept follow-up referrals; this finding is unprecedented in the history of suicide hotlines,” the authors write.

Further reading

Resources for your audience

  • The 988 Suicide & Crisis Lifeline: Call or text 988, or start an online chat at 988lifeline.org/chat. For deaf and heart of hearing, use your preferred relay service or dial 711 then 988. The old suicide prevention lifeline number, 800-273-TALK (8255), remains available and is routed to 988.
  • To reach Veterans Crisis Line, dial 988 then press 1. To text, Veterans Crisis Lifeline, text 838255. For online chat, visit veteranscrisisline.net/get-help-now/chat.
  • To reach Crisis Text Line, text HOME to 741741 for English, and AYUDA to 741741 for Spanish. The service is also available on WhatsApp at 443-SUPPORT for English and 442-AYUDAME for Spanish.
  • Find a helpline, helps individuals in any country to find free, confidential support from a real person over phone, text or online chat. Its key partners include the International Association for Suicide Prevention and the American Association of Suicidology.
  • LGBTQ+ youth can also reach out to The Trevor Project at 866-488-7386 or text 678678 to talk to someone.
  • Suicide prevention resources from the American Foundation for Suicide Prevention.
  • BeThe1To: Five steps you can take to help someone in suicidal crisis.
  • Safe Space: Coping resources has a list of free resources and tools for individuals who need some extra support in an emotionally safe environment.

Resources for reporting on suicide