Before we introduce this week’s post about important disparities in 988 utilization, by Lindsey Dawson and Heather Saunders and originally published in KFF Health News, we wanted to highlight an upcoming Symposium on Responding to Behavioral Health Emergencies being held by the Medical Care section of the American Public Health Association (among others).

 

Utilization of the 988 Suicide & Crisis Lifeline’s LGBTQ Service

(Originally published in KFF Health News May 23, 2024)

988, the federally-mandated suicide and crisis line, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), includes specific services to meet the needs of LGBTQ youth and young adults. Given that LGBTQ people face substantial experiences of stigma and discrimination, more pervasive mental health challenges, and greater unmet need for mental health services, a dedicated 988 service provides a targeted intervention for this community.

LGBT adults are more likely than non-LGBT adults to describe their mental health and emotional well-being as either “fair” or “poor” (39% v. 16%) and more likely to report being always or often anxious, depressed, or lonely over the past 12 months. Especially concerning is that, in 2021, 45% of LGBTQ high school students reported having seriously considered suicide during the past year. However, despite greater need, LGBT people are more likely to report going without a needed mental health services than non-LGBT people (see articles about additional disparities and political drivers of LGBTQ health here). Further, about two-thirds (65%) of LGBT adults say they have experienced at least one form of discrimination in their daily life at least a few times in the past year compared 40% of non-LGBT adults and experiences of stigma and discrimination contribute to mental health challenges. In addition, it has been well documented that anti-LGBTQ policy environments can negatively impact the community’s well-being and debates over LGBTQ rights are currently playing out in the courts as well as on the political stage.

This analysis examines performance metrics to assess utilization of 988’s LGBTQ service (which SAMHSA refers to as the LGBTQI+ subnetwork), compared to 988’s general service usage, from December 2023 to March 2024 (the most current and comprehensive data available). The LGBTQ pilot first launched in September 2022, but LGBTQ specific metrics did not become available to the public until December 2023.

Key takeaways include:

• During the four-month period, nearly 10% of all 988 contacts, including 16% of all texts, were made via 988’s LGBTQ service. Users can contact 988 via call, chat, or text.
• A plurality of contacts to 988 came via calls for both the LGBTQ service and the general 988 service, but those using the LGBTQ service were about twice as likely to use text.
• Those using the LGBTQ service were more likely to encounter certain challenges with the service compared to those using the general 988 service. These include double the call abandonment rate (21% v. 11%) and substantially longer call wait times (with monthly averages about double that of the general line).

What is the LGBTQ 988 service and how does it work?

A pilot for a 988 service to address the specific needs of LGBTQ young people was launched shortly after the main 988 line and later expanded to a full-time service. Recognizing the growing need for mental health crisis services in the U.S., the federal government made the mandated Suicide & Crisis Lifeline 988, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), available to all landline and cell phone users in July 2022, providing for the first time, a single three-digit number to access a network of over 200 local and state-funded crisis centers. In addition, in September 2022, 988 launched a pilot to specially address the needs of LGBTQ young people (those under 25) by offering text, phone and chat services “with a counselor trained explicitly to support LGBTQ+ youth and young adults,” but the service had limited hours. In March 2023, that pilot was expanded to run 24/7 across all modalities. (KFF provided additional history of the 988 line in an earlier brief.)

Operation of the LGBTQ line differs from the main 988 line in that services are provided through specific centers with specialty LGBTQ training rather than local crisis centers located across the country. Originally, the pilot started with one contractor (Trevor Project), but has since evolved to include seven centers (prior to the expansion, there were media reports of capacity issues and other challenges). When contacts cannot be answered by LGBTQ specific operators, they are diverted to the main 988 lines, though data on how often this occurs are not available.

What do we know about awareness and utilization of the LGBTQ 988 service?

As a relatively new service, lack of awareness of the availability of the 988 hotline may be a barrier. Recent survey data from KFF indicate that most (8 in 10) LGBT adults have heard little to nothing about the resource, similar to the share among non-LGBT adults. This low awareness is similar among young LGBTQ adults (18-29), with about 8 in 10 (78%) reporting limited or no knowledge of the 988 hotline, despite there being a service focused on supporting LGBTQ individuals under 25.

Additionally, LGBT adults report more difficulty with the standard police response to a mental health crisis call. LGBT adults are more likely than non-LGBT adults (54% v 26%) to think that that calling 911 in a mental health crisis would do more to hurt the situation than help. Given this backdrop, access to culturally competent mental health services for LGBTQ people may be particularly impactful and targeted efforts may help to increase awareness and use.

Over a recent four-month period, nearly 10% of all 988 contacts, including 16% of texts, were made via 988’s LGBTQ service (Figure 2). This is higher than the distribution of LGBT people in the population as a whole (7%). Since younger people are more likely to identify as LGBTQ, including 20% of Generation-Z, it could help to explain the relatively high rates of LGBTQ service use, especially given the service’s focus on younger people. Greater prevalence of mental health conditions and experiences of stigma and discrimination among LGBTQ people, may also, help explain high use of the 988’s specialty service.

Traffic to the LGBTQ service averaged 46,998 contacts per month over the period and increased from 45,703 contacts in December 2023 to 51,535 contacts in March 2024 (13%). Traffic increased for the general service contacts as well, albeit at a slightly slower pace (an 8% increase). Across the four-month period,187,991 individual contacts were made to 988’s LGBTQ service via calls, chat, and text. 1.8 million general service contacts were made to 988.

A plurality of contacts to 988 came via calls, for both the LGBTQ and general 988 service, but those using the LGBTQ service were about twice as likely to use text and less likely to use calls (Figure 3). Nearly one-third (31%) of LGBTQ service users contacted 988 via text, compared to fewer than one-in-five general service users (17%). While it was the most common contact modality for both groups, LGBTQ users were less likely to connect to 988 via call (58% v 70%) than general service users. The use of chat was similar for both groups (11% v 12%). In addition to promoting the service overall to improve awareness, given LGBTQ youth and young adult’s wider preference for text, promoting this modality, along with the call line, may be especially useful in servicing the needs of this population.

Callers to the LGBTQ phone line, however, faced higher call abandonment rates than callers to non-LGBTQ lines (Figure 4). The average abandonment rates for LGBTQ line callers were nearly double the rate of general line callers (21% v. 11%) (Figure 4). SAMHSA uses the term “abandoned” to describe when the person seeking 988 services hears/sees the initial 988 greeting, but is disconnected before engaging with a counselor. Per SAMHSA, this may occur due a technical reason (e.g. internet or mobile connection strength or service interruptions, etc.) or because the person seeking assistance ends the contact before a counselor answer which could also happen for a range of reasons, such as they had to wait too long or decided they were not comfortable discussing their experience. Since LGBTQ people in a mental health crisis may also fear discussing their sexual orientation or gender identity, they may be quicker to change their minds about seeking help and a prompt pick-up may improve call completion. Regardless of the reason for call abandonment, there may be opportunities to improve call experiences for users of the LGTBQ line which are nearly double the wait time of general 988 line. LGBTQ service users had lower abandonment rates for chat and the same abandonment rates for text compared to general line users.

In addition, wait time for the LGBTQ phone line was substantially longer than for 988 calls overall—with monthly averages about double that for the general line (Table 1)—which may contribute to the higher abandonment rates. The average monthly wait time for calls to the LGBTQ line were close to a minute whereas they were about 30 seconds for the general 988 service. In contrast, for other contact methods, average text and chat, wait times were shorter for LGBTQ users compared to general 988 users. While, higher than general line users, the wait times for LGBTQ callers face today may actually represent an improvement from the initial launch period of the service when media reports suggested significant challenges with wait times.