Staffing challenges led to thousands of missed calls, call center officials say.
Kristi Daugherty remembers the announcement like it was yesterday.
It was March 11, 2021-one year since the World Health Organization declared COVID-19 a global pandemic-and in those twelve months, emerging data from the Centers for Disease Control and Prevention showed that historic rates of mental illness, overdose deaths and deaths by suicide were soaring. Amid the horrific trends, the government decided to take action.
The National Suicide Prevention Lifeline was getting a makeover.
As part of the refresh, the 10-digit phone number was simplified to a succinct 9-8-8. The lifeline also added texting services, in addition to comprehensive mental health services beyond suicide prevention.
The program was supported with $200 million in funding through the Biden administration's American Rescue Plan.
As the chief executive officer at Emergence Health Network in El Paso -- which provides behavioral health, crisis response and other services to nearly 30,000 Texans a year -- Daugherty said she was excited about the developments.
But then, political pressure hit a boiling point and the launch timeline got moved up by half a year, Daugherty told ABC News. For months, EHN hustled to staff up in the face of tight budgets and tighter deadlines, she says, they didn't see a dime of federal support trickle down from Austin. The Texas Department of Health and Human Services did not respond to ABC News' request for comment on Daugherty's claim.
She's not alone in her frustration.
In some critical ways, 988 has bolstered an American mental healthcare system that the Department of Health and Human Services itself has called "long underfunded and under-resourced."
Since its launch in July 2022, the new hotline fielded over 2 million calls from people in crisis -- 45% more than the 10-digit hotline over the same period in the previous year, according to data from Vibrant Emotional Health, the organization appointed by the federal government to oversee the line.
Vibrant says the hotline has also answered over 1 million chats and texts. Average wait times have dropped from nearly 3 minutes to less than a minute. Additionally, 988 has rolled out variations of the line specifically devoted to the care of at-risk groups like veterans, Spanish-speakers and LGBTQI+ youth.
Outcome data on emergency responses, referrals to outpatient mental healthcare or inpatient stabilization services is not immediately available, according to Vibrant. But Tia Dole, the chief 988 officer at the organization, said the service has helped many people who may not have elsewhere to turn for help.
In 2021, one American died by suicide every 11 minutes, over 12 million considered suicide, and suicide was the second-leading cause of death in most youth or young adults, according to the CDC. Over 100,000 more Americans died from drug overdoses, per National Institute of Health data.
But almost one year after the crisis line's rollout-and after nearly one billion dollars of federal investment-the majority of states are still struggling to ensure that their citizens' calls get answered locally.
Unanswered calls roll over to national backup centers, but federal officials acknowledge these centers are generally less equipped to provide the local services callers may need. In April 2023 alone-the most recent month for which public data is available, according to Vibrant-states collectively missed over 11,000 calls. And in April 2023, despite stipulations to federal funding requiring answer rates above 90% by June 2022, only 15 states met that goal. Texas' call answer rate, at 75%, ranked it amongst the worst performers.
"This thing we're doing has never been done," Dole told ABC News. "Is it perfect? No."
Many of these shortcomings may relate to a particularly thorny challenge: staffing.
Crisis call centers depend on behavior health workers to man the phones - a workforce that includes psychologists and psychiatrists, nurses and social workers, counselors and coaches. The number of job openings for those types of workers is expanding "much faster than the average for all occupations," according to the Bureau of Labor Statistics.
The market for mental health counselors, for example, is expected to outpace overall job growth by 4.5-times during the next decade.
In 2020, the country required over 1 million more behavioral health workers to meet Americans' mental healthcare needs, according to federal data collected by the Government Accountability Office. That data also doesn't account for the pandemic, which took a toll on the workforce, Dole told ABC News.
"I think the workforce, with regards to crisis services, has not recovered since [the pandemic]," Dole told ABC News.
The workforce shortages have meant crisis call centers across the country have struggled to staff up. According to data reviewed by ABC News from state health departments, in Rhode Island, 52% of positions were empty as of May 2023. In Wisconsin, 30% of positions were empty. According to a 988 jobs board maintained by the Substance and Mental Health Services Administration (SAMHSA), nearly every state in the country has vacancies.
For Vince Brancaccio, the labor scarcities are a daily struggle.
Brancaccio, who is the chief executive officer at Health Network of Southeast Ohio-one of the state's 988 centers-is spending a significant part of his days now simply trying to find interested candidates. That's instead of doing the work of crisis stabilization and mental healthcare itself, Brancaccio told ABC News.
Most of the time, his days spent hiring are riddled with frustration by way of empty Zoom rooms. More often than not, candidates "don't show for interviews," Brancaccio said. Or if they're hired, he said, "they don't show for the job the first day." About half of the 988 chairs at his center are empty, he said.
Another challenge call centers are facing around staffing relates to managing remote versus in-person work.
In a post-pandemic world, remote work has become standard, according to a 2021 McKinsey report, especially for computer-based office work, like answering calls. However, many 988 centers -- like Brancaccio's -- are not offering remote work: according to the SAMHSA 988 jobs page, over 70% of centers are in-person only.
Additionally, fewer than 5% of 988 centers currently use Vibrant's new software platform -- the development of which was funded in part by federal money -- to answer calls, Dole told ABC News. Many are still using legacy software whose origins stretch back to the 2004 launch of the pre-988 lifeline-software that too often is ill-equipped to handle the complexities of remote work almost two decades later, Dole said.
These dynamics mean that states with already-scarce behavioral health workers are experiencing a brain drain, Joshua Thomas, the chief executive officer at the Delaware chapter of the National Alliance on Mental Illness, told ABC News. According to a December 2022 study by the Delaware Department of Health and Social Services, there is a widespread shortage of mental health resources in the state.
Thomas said that lack of flexibility around remote work-combined with "an income potential that is significantly lower than it is elsewhere"-present the risk that states like his will struggle to compete with others who are better resourced or more flexible.
In comparison, states like Massachusetts-which devoted $10 million from state coffers to 988, increasing wages and providing hybrid work options-has more than doubled its staff since the hotline's rollout, according to Vibrant. Massachusetts' call answer rate in April was 88% -- just under SAMHSA's 90% answer rate threshold -- compared with Delaware's 73%, according to date collected by Vibrant.
Daugherty worries that the accelerated timing of the rollout was short-sighted: the rush to announce 988-followed by the scramble to get it operational and the struggles that have ensued-may have undercut trust in the line over the longer-term.
At the time of the hotline's launch, HHS Secretary Xavier Becerra said that "988 is more than a number, it is a message: we're there for you." Eleven months later, amid centers' struggles to staff up, Daugherty compares those promises to gift-wrapping an empty box.
Monica Johnson, SAMHSA's 988 director, acknowledged the hotline's growing pains so far. But Johnson also pointed towards the progress of the hotline to date-over 3 million contacts answered, shrinking wait times, almost $1 billion invested-as signs that things are moving in the right direction.
"I think about, okay, what month are we in into this first year-[and] did we demonstrate that we have the capacity to answer the calls?" Johnson told ABC News. "The answer to that, so far, has proven to be yes."
Still, for people like Molly Jacobson, those growing pains are a matter of life and death.
Jacobson, a Florida native, said she called the line in October 2022 on behalf of a loved one in crisis. A relative had attempted suicide before, and she worried, might do so again. However, when she dialed 988, she says she was immediately put on hold.
When she finally spoke with someone, after a series of triage questions, the operator sounded resigned, she said. "'I'm sorry, I don't know what I can offer,'" Jacobson recalls him telling her.
Jacobson said she didn't know where else to turn.
She said, "For something that's funded by hundreds of millions of dollars...where's all that going?"
Jacobson's experience highlights some of the challenges the state has had so far: in April, Florida received over 10,000 calls, of which it answered only 73%--putting it amongst the worst performing states. Florida's Department of Children and Families, which oversees the management of the 988 hotline in the state, did not respond to ABC News' request for comment on Jacobson's case.
Jacobson says her loved one ended up fine despite the negative experience with the line. But she worries about what might happen next time-or, to someone else in a similar situation.
"When any of us are in our darkest hour," Jacobson said, "what we need is to be heard."
Despite some of the staffing challenges, if you or a loved one is struggling with a mental health crisis or considering suicide call or text 988.
ABC News is looking into challenges and successes with implementation of the 988 Suicide and Crisis Lifeline. If you have had issues or successes with the line, please email firstname.lastname@example.org.
Michal Ruprecht, a member of the ABC News Medical Unit, contributed reporting.