Columbia Suicide Research Culminates in New National Hotline Number

When Madelyn Gould, PhD, MPH, first started evaluating suicide hotlines in 2001, the services were not held in high regard by the mental health community. The Surgeon General’s 1999 Call to Action to Prevent Suicide made no mention of crisis hotlines.

“Hotlines were manned by volunteers and they had the reputation of really not doing much,” says Gould, the Irving Philips Professor of Epidemiology in the Department of Psychiatry at the Columbia University Vagelos College of Physicians and Surgeons. 

“There was a perception that the only people calling crisis hotlines were lonely, middle-aged women who just needed somebody to talk to. Not people who were truly suicidal.”

But the work by Gould since 2001, and now others, firmly established suicide crisis hotlines in the nation’s efforts to prevent suicide.

In 2001, 130 of the nation’s crisis hotlines, which were run by different organizations, were made accessible and linked by one single number: 1-800-SUICIDE and subsequently by 1-800-273-TALK (8255). Currently, there are approximately 170 crisis centers in the National Suicide Prevention Lifeline, the national network of crisis hotlines.  

On July 16, the Federal Communications Commission (FCC) voted to create a single, shorter, easier to remember number–988–to access the National Suicide Prevention Lifeline’s network of crisis services. The new number will take effect in July 2022. 

The CUIMC Newsroom talked to Gould just before the FCC voted; below is an edited version of the conversation.

How do you think 988 will help?

The major benefit is that it will make crisis services more accessible to people who are in need. When people are overwhelmed and in crisis, their cognitive ability is overwhelmed; a shorter number should make it easier to recall. 

There are about 2 million calls each year to the National Suicide Prevention Lifeline, and I would anticipate that once 988 is up and running, the numbers are going to grow drastically.

There are a lot of people in need in the United States. In 2018, about 48,000 people in the United States killed themselves. Many more people have suicidal thoughts, and so many of them are not getting the care that they need. 

Calling the hotline doesn't cure someone, but it's the gateway to other resources and treatment.

What got you interested in researching suicide prevention hotlines, given they weren’t really respected when you began?

Around 2000, the Substance Abuse and Mental Health Services Administration [SAMHSA] began funding a national network of certified crisis centers and they put out a request for applications to evaluate it.

The goal of our first projects was to measure the centers’ effectiveness. Did the counselors have the ability to change the callers’ crisis or suicide states from the beginning to the end of the call?

What did you find?

We interviewed about 3,000 callers from a representative sample of crisis centers and found significant reductions in callers’ self-reported crisis and suicide states from the beginning to the end of the call. 

We also busted a common misconception at the time that suicidal people weren't really calling the hotlines. We found that seriously suicidal individuals were calling the services; 8% were actually in the midst of an attempt, and 58% had made a prior suicide attempt.

What happens during a call?

The crisis counselor will engage with the caller to help the caller feel validated and connected, similar to building a therapeutic relationship. A counselor actively listens, not just talks at a caller. They try to understand what is going on in the caller's life to have created this crisis situation.

They will artfully work in a suicide risk assessment to find out if someone is currently suicidal and the extent to which they may be planning to act on their suicidal thoughts. Are they alone? Are they intoxicated? Do they have a gun or other lethal means readily available? If someone says that they're feeling suicidal, there's no knee jerk reaction to call the police, and instead they will start working collaboratively with the caller to see what they have done in the past to get past their crisis. Or if this is their first time feeling suicidal, are there people in their social network that they can reach out to?

We’ve found that the crisis counselors at the National Suicide Prevention Lifeline have the skills to reduce the crisis to the point where the caller is not at imminent risk. So, for maybe 60% of callers at imminent risk when the call begins, counselors do not have to call emergency services. 

Even when they have to call emergency services, the counselors are usually able to collaborate with the caller, so the caller agrees to a visit from emergency services. Callers still need care, of course. They still need interventions and connections with mental health professionals, but the hotline counselors help them stabilize until they can get linked to a mental health resource.

Is chat as effective? Can people call on behalf of someone in crisis?

We’ve been evaluating the crisis chat program that the National Suicide Prevention Lifeline started in 2013. The chat service draws a younger audience compared to the phone service, and we’re looking to see if it is effective.

We’re also finishing up a study focusing on the “third party callers” who call on behalf of someone else who is at imminent risk. We know that at-risk individuals who don't call on their own can be at higher risk than the people who do call on their own. 

Our study found that the crisis counselors can actually do a risk assessment of someone at risk based on the information that a third party provides. And the crisis counselors can work with the third-party caller to either get the person in crisis to an emergency department or find other ways to help keep them safe.

The National Suicide Prevention Lifeline has tried to share with the public the message that if you're worried about someone, call the Lifeline. Other suicide prevention organizations have also used public messaging to encourage people to call the Lifeline on behalf of someone else who is suicidal. And I think based on our initial findings, people can be confident that their calls can indeed help the person in crisis.

Why do you continue studying the hotlines?

After each study, in addition to finding evidence for hotlines’ effectiveness, we usually identified some room for improvement, which SAMHSA would use as rationale to start funding services to fix those problems, and they would then ask us to evaluate the changes. It’s become an iterative process over the years.

In our first study, we found about 40% of callers had some recurrence of their suicidal ideation in the weeks after their crisis call and only about 20% had followed through with the referrals that they had been given.

Because of our findings, SAMHSA started funding Lifeline crisis centers to conduct follow-up calls to enhance the caller’s continuity of care. And when we interviewed those callers, about 80% said that this follow-up actually had stopped them from killing themselves.

We’ve now had about 65 crisis centers participate in one or more evaluations. We built trust with the centers; we’re trying to identify whether their services are effective, and if not, how can they be improved?

I'm pleased that some of my other research has also had an impact, for example by showing that it’s safe to ask people about their suicidal thoughts and it doesn’t put ideas into their heads.

The crisis hotline research has been particularly gratifying; our findings are put into effect almost immediately to improve the practices of the Lifeline. 

Suicide hotlines are now thought of as a key part of the mental health system of care for people in crisis.