When it comes to preventing suicide, every minute counts. Every minute in the United States, a person makes a suicide attempt. Every 16 minutes, a person ends his/her life. Each minute, then, becomes an opportunity to provide immediate mental healthcare and prevent a person from dying by suicide.
A growing network of community health centers, community mental health centers, nonprofit organizations, and other facilities provide care when people are facing suicidal crises. Lives are saved because of the dedicated professionals who staff these care centers, from doctors and nurses to counselors and therapists. Yet, few centers have the resources to operate 24 hours a day, 7 days a week. Mental health counselors and other care providers face the difficult task of providing their patients with adequate resources for after-hours help, sometimes in communities where the hospital emergency department (ED) is the only option if a crisis occurs during nontraditional hours. Care providers also need resources to give to people in crisis and their family members to explain what to do when they cannot access traditional methods of care. For example, what should people do when they lack transportation to get to their appointments or during a crisis when they need immediate support?
Research shows that EDs treat the majority of suicide attempt survivors. Every year, many thousands of people facing a suicidal crisis seek care in EDs because they offer around-the-clock care and open access. While EDs can provide some immediate help, they often are overused and inappropriate as a “first option” for people in emotional crisis and considering suicide.
EDs typically are designed to provide assessment for hospital admission and while psychotropic medications frequently are dispensed for ED discharges, EDs are not best suited for therapeutic interventions and supportive counseling assistance. It can be extremely difficult for overburdened EDs to provide the full range of services that people in crisis need; 90% of those who die by suicide have a treatable mental illness but require care beyond what they received in the ED.
Suicide attempters who have been admitted to hospitals can fall between the cracks postdischarge, never reaching the community-based mental health services that the hospital has referred them to in their discharge plan. Recent research has shown that the risk of suicide only one week after discharge from psychiatric hospitalization is up to 102 times higher for males and 60 times higher for females when compared to the general population's risk, indicating a need for rapid, efficient aftercare linkages to community mental health services.1 Unfortunately, if recent findings from California are any indication, ED personnel report a remarkable lack of community mental health resources with which to refer high-risk patients.2 So how can ED staff, inpatient discharge planners, and community mental health service providers fill these potentially fatal gaps in our behavioral health systems?
While crisis hotline services are not the only answer, they are a critical, underutilized resource for filling service gaps and supporting people at risk in overburdened community behavioral health systems. Crisis lines, such as many of the certified call centers participating in the federally funded National Suicide Prevention Lifeline network, offer 24/7 access to trained workers who can provide assessment, supportive counseling, and crisis intervention for people in emotional or suicidal distress in communities across America.
Research indicates the potential value of crisis lines in filling treatment access and continuing care gaps in behavioral health systems. New findings have shown that crisis call centers can reduce emotional distress and suicidality in callers, with clear indications that lives have been saved.3,4 Other research has shown that utilizing call center services to provide follow-up care postdischarge from EDs has positive effects on people with mental health problems, including enhancing treatment linkages and reducing emotional distress and suicide attempts.5-7 Furthermore, clients receiving community mental healthcare can benefit from using hotlines between therapy sessions.8 Vaiva et al demonstrated that at times patients were more open to telephone contact than an in-person appointment at a psychiatric clinic.7
Because of their unique all-hours, in-home accessibility to trained counselors, crisis hotlines provide a means of delivering behavioral health services to clients who may be unwilling or unable to seek or maintain care in traditional behavioral health settings. Uninsured people and individuals living in remote areas, along with crises occurring at any time, necessitate ready access to affordable mental health supports at all hours. In some cases, expecting people who have major depression, agoraphobia, or other disabling mental health conditions to leave their homes (or beds) to attend outpatient sessions could be analogous to putting a spinal cord injury clinic at the top of a steep staircase, as a colleague in the telephone counseling business put it. Clearly, crisis lines can be a critical supplement to expanding community behavioral health delivery options for the wide range of illnesses and functional impairments that confront our systems of care.