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As U.S. launches new crisis hotline, nearly half of counties lack response teams

July 26, 2022
by Ashley Liebre

A new 988 Suicide and Crisis Lifeline launched by the U.S. government is supposed to make it easier for people experiencing a mental health crisis to get help. But a new Yale study finds that not all Americans will have the same access to appropriate follow-up care.

The 988 Lifeline, which went into effect on July 16, replaces the National Suicide Prevention Lifeline and offers expanded services, including support for people struggling with substance use and other behavioral health issues. The Lifeline is intended to direct calls to mental professionals — including crisis intervention teams (CIT) if necessary — rather than law enforcement.

While most callers’ needs can be met over the phone, about 10 to 20% of calls require an in-person response to further assess the situation or transfer the caller to an appropriate care facility if necessary, according to the Yale study. But not all U.S. communities have access to crisis teams to provide that critical in-person support.

A study by researchers at the Yale School of Public Health (YSPH) found that nearly half of all U.S. counties — 1,512 of 3,142 (48%) — lacked access to a facility providing community CIT services in 2020. While almost 90% of U.S. residents live in a county with access to CIT, one in nine U.S. residents live in counties without access to these services. The problem is particularly acute in rural areas. Researchers found that counties without access to crisis intervention teams tended to have a greater percentage of older and uninsured residents. They also were the counties with higher suicide mortality rates.

“This is concerning because rural America has some of the highest suicide rates and significant mental health needs,” said Helen Newton, a postdoctoral fellow at YSPH and the study’s lead author. The study appears in JAMA Network Open.

The cross-sectional study looked at 10,591 mental health treatment facilities in all 3,142 counties across the 50 U.S. states and the District of Columbia that were listed in the 2020 National Directory of Mental Health Treatment Facilities, which is maintained by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). The directory notes which facilities offer a crisis intervention team. The authors identified the counties in which those facilities were located as of 2015, and 2020 respectively. They then assessed how access to crisis intervention teams was associated with regional social and demographic characteristics, and state Medicaid policies.

The researchers also assessed whether available crisis intervention services improved over time. They found that one in five counties experienced a change in access to CIT between 2015 and 2020, though the net number of counties with access to CIT support did not change. Approximately 9% of all counties lost access; approximately 9% of all counties gained access.

This is concerning because rural America has some of the highest suicide rates and significant mental health needs.

Helen Newton

The new 988 Lifeline is expected to increase demand for community behavioral health services, which was already on the rise prior to COVID-19, according to the American Hospital Association (AHA). According to the AHA, 21% of U.S. adults (an estimated 52 million people) have mental, behavioral, or emotional disorders.

More federal funding support for behavioral health could help communities provide critical CIT services, the researchers said. According to the study, counties that expanded Medicaid eligibility under the Affordable Care Act were more likely to have mental health facilities that provided CIT.

“This is important because under the current fiscal year allocations included in the American Rescue Plan, state Medicaid agencies now have the statutory authority and resources to invest in crisis intervention services and greater flexibility to develop programs tailored to their communities,” said Susan Busch, professor of public health (Health Policy) at YSPH and the study’s senior author.

YSPH doctoral student Tamara Beetham is a co-author. The research was supported by grants from the National Institute of Mental Health and the Agency for Healthcare Research and Quality.

Submitted by Colin Poitras on July 23, 2022