The US mental health hotline network is expanding, but rural areas are still disadvantaged

The National Suicide Prevention Lifeline’s 988 phone number, which launched on July 16, was designed as a universal mental health support tool for callers anytime, anywhere.

But the United States is a patchwork of resources for crisis relief, so what comes next is not universal. The level of support that 988 callers receive depends on their zip code.

In particular, rural Americans, who die by suicide at much higher rates than residents of urban areas, often have trouble accessing mental health services. Although 988 can connect to a call center near their home, they may end up being directed to remote resources.

The new system is supposed to give people an alternative to 911, yet callers from rural areas who are experiencing mental health crises may still be met by law enforcement personnel instead of mental health specialists.

More than 150 million people in the United States—mostly in rural or partially rural communities—live in areas designated by the federal Health Resources and Services Administration as mental health professional shortage areas. This means there aren’t enough mental health providers – usually psychiatrists – to serve the population in their communities

The Biden administration distributed about $105 million to states to increase local crisis call center staffing for the new 988 system. But states are responsible for filling any gaps in the continuum of care that callers rely on if they need more than a phone conversation. States shoulder most of the responsibility for staffing and funding their 988 call centers when federal funding dries up.

The federal Substance Abuse and Mental Health Services Administration, which operates the existing 800-273-8255 lifeline that expands on 988, says a state that implements a successful 988 program must ensure that a mental health professional is available to speak with the caller. There’s a mobile crisis team to respond, and places to go — such as a short-term residential crisis stabilization facility — that provide diagnosis and treatment. The federal agency also intends for 988 to reduce reliance on law enforcement, expand access to mental health care and reduce pressure on emergency rooms.

These objectives may not be uniform across states or communities.

If there’s no mobile crisis team to send to a call center, “you don’t have stability, then you’re basically going from the call center — if they can’t meet your needs — to the emergency room,” says Dr. Brian Hepburn, executive director of the National Association of State Mental Health Program Directors. The group created Model 988 legislation for states that emphasizes consistent service requirements regardless of collar location.

For the new call system to be consistent, “you really need that full continuum of care,” Hepburn said. “Not expecting it to be available now. The hope is,” he said, “that your kingdom will eventually take you there.”

But since 988 was introduced, most states haven’t passed legislation to address mental health care gaps.

In South Dakota, which has the eighth-highest suicide rate among states, health officials say responding to mental health crises in rural counties will be a challenge. So they plan to include volunteer emergency medical services and fire department personnel in emergency response to 988 calls on the ground. More than two-thirds of South Dakotans live in areas with a mental health professional shortage.

According to South Dakota Department of Social Services Cabinet Secretary Lori Gill, the state has only one professional mobile crisis team that responds to emergencies in person. The Mobile Response Team is located in Sioux Falls, South Dakota’s largest city, and serves the southeast corner of the state.

“Some of our communities have virtual mobile crisis teams,” said Janet Kittams, CEO of the Helpline Center, a South Dakota nonprofit that answers the state’s 988 calls. “Some of our communities have co-reactive models. Some of our communities will respond directly to law enforcement. So it really varies quite a bit across the state.”

Sioux Falls is home to one of the state’s two short-term crisis facilities. The other is more than 300 miles away, in Rapid City. South Dakota has 11 community mental health centers that evaluate patients and provide outpatient treatment. These centers also use law enforcement agencies to respond to mental health crises.

A helpline center counselor can direct a 988 caller to one of those centers.

“Sometimes, yes, you have to drive hours to get to a community mental health center, but sometimes not,” Kittams said. “Generally speaking, people who live in rural parts of South Dakota are more likely to have to drive to a resource, because that’s probably true in other aspects of their lives, not just for mental health care, but for other types of care or resources that They need it.”

The helpline center reports that its operators de-escalate 80% of calls without deploying a crisis team. But Vibrant Emotional Health, a nonprofit that co-administers Lifeline nationwide, estimated a fivefold increase in calls for South Dakota in the first year to 988. Any spike in calls will likely increase demand for crisis teams.

Vibrant says 988 will reach at least an additional 2 million people nationwide in its first year. Half of those mental health-related calls are expected to come from 911 and other crisis centers dispatched to 988.

Right next to South Dakota, Iowa entered the 988 era with a more robust mobile crisis response system — “at least on paper,” said Peggy Huppert, executive director of the Iowa chapter of the National Alliance on Mental Illness. Eighty-seven of the state’s 99 counties have a mobile crisis provider, but most Iowans live in areas with a mental health professional shortage.

The remaining 12 counties — all rural — rely on law enforcement and emergency medical technicians, Huppert said.

“We still need to properly train all first responders, especially law enforcement, because law enforcement is trained to come to a scene and take control of the scene,” he said. “People who are in behavioral health crises, who are probably psychotic, sometimes they’re hearing voices, they’re hallucinating, they’re in an altered state. They are not inclined to follow orders. That’s where things often go wrong.”

Officials at a 988 call center for nine counties in east-central Iowa operated by Community Crisis Services said their mobile crisis teams would consist only of counselors but that law enforcement agencies could be called in if a team determined it was necessary for its safety.

Community Crisis Services has three mobile crisis service providers who arrive in unmarked vehicles.

Adrienne Korbecks, chief operating officer of Community Unity, said mobile crisis teams are a great option in rural communities where mental health treatment can carry a stigma. And with 988, he said, “you can call or text or chat from the privacy of your own home — no one has to know you’re accessing the services.”

To prepare for these introductions, Community has nearly doubled its staff over the past seven months — from 88 employees in January to 175 in July.

Despite 988 preparations in Iowa and South Dakota, no state legislature has funded the measure long-term. In the National Suicide Hotline Designation Act of 2020, Congress gave states the power to cover 988 costs by adding surcharges on cellphone service, but most have not.

According to the National Alliance on Mental Illness, only 13 states have enacted 988 laws, with varying applications and prescriptions across the continuum of care.

In Iowa, Huppert says, “there’s a lot of wait-and-see approach.”

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