If you or someone you know is in crisis, please call, text or chat with the Suicide and Crisis Lifeline at 988, or contact the Crisis Text Line by texting TALK to 741741.

When 24-year-old Marie texted 988 last December, she was in the middle of a dissociative episode that left her unable to speak.

"I just remember shaking and being on the floor and not knowing how to get my soul back to my body," Marie says. "All I could feel was fear."

Over the course of an hour, a counselor helped Marie reconnect with her senses in part by encouraging her to take concrete steps like making a cup of hot chocolate and running her hands under warm and cold water.

"She was able to kind of pull me back into myself," Marie says. (NPR agreed to use Marie's middle name only because her mental health challenges are related to a past abusive relationship.)

Marie's experience is one of about 5 million calls, chats and texts fielded by the new, 3-digit national crisis line in its first year of operation. Federal officials say that's up 35% compared to the old 10-digit line.

Last July, the cumbersome 10-digit National Suicide Prevention Lifeline became 988. The easy-to-remember lifeline was created to help people dealing with issues like depression, substance use and suicidal ideation get immediate help and be guided to additional resources. At the one-year mark, there's some success to report: Texts to the lifeline increased dramatically and average wait times across the line plummeted from 2 minutes 39 seconds to 41 seconds.

"I am gratefully surprised at how smoothly everything has worked," says Jennifer Battle, who runs 988 for the Harris Center in Houston, Texas. "I was expecting the volume to be so significant so quickly that we would feel like we were drowning."

Still, mental health leaders say more work is needed urgently to meet the line's full potential and save lives. Federal statistics show more than 14 million adults in the U.S. had a serious mental illness in 2021, and 12.3 million seriously considered suicide. In particular, the rates of suicide and mental illness among young people are a growing concern among mental health advocates and policymakers.

The Biden administration has invested nearly $1 billion to launch 988, and some states have also poured resources into the new line. Much of this funding has gone to more than 200 local call centers around the country to boost staffing. Staffing shortages have been such a concern that federal officials delayed a major media campaign to promote the line.

Nearly every state still reports open positions, but many local and national 988 leaders say raising awareness has become their top priority. Only 18% of adults in the U.S. are aware of 988, according to a survey released in May by the Pew Charitable Trusts.

"My biggest worry is that there are folks who are suicidal or family members who need help for suicidal family members or loved ones, and they don't know that we exist," says Tia Dole, Chief 988 Officer for Vibrant Emotional Health, the nonprofit that administers 988. Dole said Vibrant plans to launch a national awareness campaign this fall.

Texting sees significant growth

In the last year, 988 has answered more than 665,000 texts, an 1,135% increase from the 10-digit National Suicide Prevention Lifeline the year before 988 went live. The 10-digit line only added text in 2020. In an average month, about 40% of texts on the old line went unanswered, and it took an average of 15 to 30 minutes for someone to respond.

"If we do not have robust infrastructure that connects you locally for chat and text, we're not keeping up with the times, and we are not reaching some of the key target populations," says Monica Johnson, the director of the 988 and Behavioral Health Crises Coordinating Office at the federal Substance Abuse and Mental Health Services Administration.

Responding to texts requires additional staff, new trainings and a special technology platform new to most centers. At least 29 states have local call centers answering texts, while the rest rely on centers in other states.

Shawn Kinney, a 988 counselor at First Choice Services in West Virginia, says he's learned that young people in particular are more comfortable texting about difficult subjects. Kinney says it also allows people to seek help safely, regardless of where they are or who they're with. He's received crisis texts from people on buses, kids hiding from bullies in school bathrooms, and even people sitting next to their abusers.

"A lot of people would not reach out to us if it wasn't for that [texting] option," Kinney says.

Texting was the right option for Marie. She had experienced these kinds of attacks before, a symptom of the complex PTSD she was diagnosed with after a three-year relationship with an abusive boyfriend. But it was the middle of the night, and Marie was in Honolulu finishing a master's degree in marine biology — 5,000 miles away from family and friends.

Marie's therapist just that week had suggested 988 could be helpful in a crisis. The line connected Marie to a counselor who kept communicating with her until she felt better.

"It's what I needed. I'm really thankful," Marie says.

Balancing quick response with privacy

The goal of 988 is to connect people in crisis with someone in their community who can point them to local resources if needed. Some states fare better than others. Mississippi answered 98% of in-state contacts in May 2023, while South Carolina managed just 67%, with the rest answered by a network of national backup centers.

But providing someone with a local response can be challenging when it comes to ensuring privacy and routing calls in the cell phone era.

Individuals who contact 988 are funneled to a call center based on their phone's area code, but that area code might not reflect where a person is actually calling from. Deborah Turner says the call center she runs in Rochester, New York, regularly gets calls from former state residents who now live in Florida. As a workaround, the website for Jennifer Battle's agency in Houston encourages people within Harris County to call the county's separate 10-digit crisis line instead of 988 to guarantee a local response.

Tia Dole at Vibrant said 988 is currently testing technology used by many 911 centers that would allow 988 to identify the call center closest to a person reaching out while keeping their precise location hidden. Federal Communications Commission Chairwoman Jessica Rosenworcel told a congressional committee in June that the FCC, which would need to green light the use of such technology, is working with federal health officials and telecom executives to find a solution. Neither Rosenworcel nor Dole offered a timeline.

Fears of unwanted police interactions persist

Many people view 988 as an alternative to 911 — a chance for the country to move away from law enforcement responding to mental health crises. But half of LGBTQ+ people in a recent survey by Pew Charitable Trusts said they worried a call to 988 could end in an unwanted interaction with police or a forced hospitalization.

988 officials say working with 911 to send emergency services to someone who doesn't want them is rare and done only as a last resort. They argue the policy is designed to minimize the number of people dying by suicide.

Some transgender advocates say this approach poses an unacceptable risk to trans people and could increase their risk of future suicidality. Some in the transgender community, including clinicians, remain wary of 988, even though nearly half of transgender youth considered suicide last year.

Kellan Baker, executive director of the Whitman-Walker Institute, an LGBTQ+ research and advocacy organization, says the growing wave of bans on gender-affirming care and participation of transgender athletes in sports also makes it difficult for trans people to trust a government-run hotline like 988.

"It's a terrible environment to try to be making the argument that the government is here to help," Baker says.

At the same time, Baker appreciates the nearly $40 million the Biden administration has invested in 988 services focused on the LGBTQ+ community. Last September, 988 launched a pilot program that gives callers the option to press 3 to talk with a counselor from the Trevor Project — a nonprofit with its own LGBTQ+ crisis line. Federal officials say 6% of all 988 calls and 15% of texts since last September have gone to that special line, and six other call centers joined the Trevor Project in answering these contacts on a permanent basis this summer.

Tia Dole at Vibrant considers 988's work with LGBTQ+ individuals one of the new line's biggest achievements and believes greater transparency about 988's policies will strengthen trust with trans communities.

Looking ahead

Finding sustainable staffing and funding models remain top priorities as 988 enters its second year. Congress allowed states to fund 988 the same way 911 is funded – through dedicated cell phone fees. Eight states have done this so far. Every other state is relying on unpredictable federal and state funding.

Many experts also emphasized the need to build out the continuum of services that come after someone calls 988, including mobile crisis teams staffed by mental health professionals – instead of police. Most states have mobile crisis teams, but only 17 states had them available statewide and 24/7 as of last fall.

Hannah Wesolowski, the Chief Advocacy Officer for the National Alliance on Mental Illness, says 988 has made significant strides in its first year but cautioned that more work is needed.

"Everyone always talks about how it took decades to build the 911 system, and it did. But if we take decades to build this system, we're going to lose a lot of lives," she says.

This story comes from the health policy podcast Tradeoffs. Dan Gorenstein is Tradeoffs' executive editor, and Ryan Levi is a reporter/producer for the show. Tradeoffs' coverage of mental health is supported in part by the Sozosei Foundation.

Copyright 2023 TRADEOFFS. To see more, visit TRADEOFFS.