Journal Article Annotations
2025, 1st Quarter

Emergency Psychiatry

Annotations by Rida Khan, MD and Clayton Barnes Martinez, MD
March, 2025

Changes in Specialty Crisis Services Offered Before and After the Launch of the 988 Suicide and Crisis Lifeline.

Of interest:

The Promise and Perils of Using Peers and Other Paraprofessionals as Mental Health Service Professionals.

Editorial: Why Are Children Hurting Themselves and What Can We Do?

PUBLICATION #1 — Emergency Psychiatry

Changes in Specialty Crisis Services Offered Before and After the Launch of the 988 Suicide and Crisis Lifeline.

Jonathan Cantor, Megan S Schuler, Rose Kerber, Jonathan Purtle, Ryan K McBain

Abstract: JAMA Psychiatry. 2025 Jan 29:e244548. doi: 10.1001/jamapsychiatry.2024.4548. Online ahead of print.

Importance:
The launch of the 988 Suicide and Crisis Lifeline (988) in July 2022 aimed to enhance access to crisis mental health services by replacing the National Suicide Prevention Lifeline with a more memorable number and expanding the Lifeline scope beyond suicide. However, 988’s success relies on the availability of community crisis services.

Objective:
To examine whether the launch of 988 was associated with the availability of crisis services.

Design, setting, and participants:
This cohort study characterized trends in crisis services offered by US mental health treatment facilities (MHTFs) from November 1, 2021, through June 30, 2023. Longitudinal data were from the Mental Health and Addiction Treatment Tracking Repository, which contains daily instances from the Substance Abuse and Mental Health Services Administration’s Behavioral Health Treatment Locator. The analysis includes licensed MHTFs that completed the National Substance Use and Mental Health Services Survey. Proportions of facilities offering 4 specific crisis services were calculated nationally and at the state level. Mixed-effects logistic regression was used to assess changes in availability of each crisis service after the launch of 988, controlling for MHTF characteristics.

Exposure:
Launch of 988 in July 2022.

Main outcomes and measures:
Outcomes were the availability of mobile crisis response services, psychiatric emergency walk-in services, suicide prevention services, or peer support services.

Results:
Across 15 623 MHTFs (184 769 observations; 79 268 before and 105 501 after the 988 launch), the largest changes were observed for availability of peer support services, which increased from 39% (n = 31 170) before to 42% (n = 44 630) after the 988 launch (P < .001), and emergency psychiatric walk-in services, which decreased from 32% (n = 25 684) before to 29% (n = 30 300) after the 988 launch (P < .001). When controlling for MHTF characteristics, after the 988 launch, the odds of peer support availability increased 1.3% per month (odds ratio, 1.013; 95% CI, 1.009-1.018), and the odds of emergency psychiatric walk-in service availability decreased by 0.6% per month (odds ratio, 0.994; 95% CI, 0.989-0.999). Availability of other service types also decreased at the national level, with mobile crisis response decreasing from 22% (n = 17 071) before to 21% (n = 22 023) after the 988 launch and suicide prevention decreasing from 69% (n = 54 933) before to 68% (n = 71 905) after the 988 launch. Significant variation across states was observed in service availability trends before and after the 988 launch.

Conclusions and relevance:
This study found that the launch of 988 did not coincide with significant and equitable growth in the availability of most crisis services except for a small increase in peer support services. These findings suggest that strategies are needed to boost the financing and availability of crisis services to reduce disparities and increase 988’s likelihood of success.

Annotation

The finding:
The July 2022 launch of 988 Suicide and Crisis Lifeline effected a modest shift in pre-emergency room psychiatric mental health crisis care across 15,623 mental health treatment facilities studied in this cohort study. Peer support services trended to an increase from 39% to 42%, concurrent with a decrease in psychiatric walk-in services (32% to 29%) and decrease in both rates of mobile crisis response (22% to 21%) and suicide prevention services (69% to 68%)—these findings were statistically significant. Within the context of overall emergency care delivery, these changes noted did not coincide with a greater availability of crisis services, and significant disparities in emergency psychiatric care persist.

Strength and weaknesses:
Significant differences exist in psychiatric emergency care delivery across US states. Limitations of this study include inconsistent reporting of measurement variables across mental health facilities, specifically what constituted peer support services and what setting they were available in. Being a retrospective cohort study, the authors could not control for variables, specific diagnoses or management implemented post-contact, i.e. whether patients were hospitalized inpatient or connected with longitudinal outpatient care. The rates of changes noted, while appearing minimal, did achieve statistical significance likely due to large sample size studied.

Relevance:
The launch of 988 was intended to increase accessibility to psychiatric emergency care in the setting of a significant unmet need for crisis care, which in turn perpetuated burden of significant shortages in downstream care including mobile teams, crisis stabilization centers, and inpatient beds. Despite this effort, access to mental health crisis care remains inadequate, disparate across states and communities, and significant unmet needs persist.

PUBLICATION #2 — Emergency Psychiatry

The Promise and Perils of Using Peers and Other Paraprofessionals as Mental Health Service Professionals.

Patricia A Areán, Stephen O’Connor, Joel Sherrill

Abstract: JAMA Psychiatry. 2025 Feb 1;82(2):107-108. doi: 10.1001/jamapsychiatry.2024.4276.

Annotation (unstructured)

This JAMA Opinion article by Arean discusses the advantages and potential drawbacks of utilizing paraprofessionals to address the mental health workforce shortage. Peers and other paraprofessionals can provide psychoeducation, care coordination, and other supports, all facilitated by an individual with lived experience, thereby reducing the potential stigma associated with receiving care. In the best use case, paraprofessionals share responsibilities within the team commensurate with their training and in line with patient needs. However, the role of a peer remains largely undefined, occasionally approaching that of a counselor or therapist, albeit with minimal training or certification. Arean and colleagues also highlight the current state of the evidence for the use of peers – which is mixed – and the low reimbursement rates for services that hamstring widespread implementation of paraprofessionals in clinical settings. Finally, a success story for the use of peers and paraprofessionals from Washington State is shared, highlighting the critical elements of implementation: appropriate training, a livable wage, and a “task sharing” model of care (as opposed to shifting care requirements to unlicensed peers).

PUBLICATION #3 — Emergency Psychiatry

Editorial: Why Are Children Hurting Themselves and What Can We Do?

Randy P Auerbach

Abstract: J Am Acad Child Adolesc Psychiatry.

Alarmingly, suicide is now a leading cause of death for preadolescent youth (ie, less than 13 years of age), and among community samples, 2.56% report lifetime suicide attempts with 15.08% experiencing suicidal ideation.¹ Predictable but preventable factors have conspired to propel us toward this public health crisis. Chief among them is that approximately 45% of individuals in the United States reside in communities with shortages of mental health professionals,² a problem that is disproportionately affecting youth of color. The reduced access to psychiatric care means that treatment for many preadolescent youth, particularly during non-acute periods when many interventions are most effective, is delayed given limited clinician availability. Furthermore, the increased acuity of the modal case may be contributing to clinician burnout, further diminishing an already beleaguered workforce. Moreover, societal cracks present prior to the COVID-19 pandemic were further exacerbated, including increased loneliness and isolation³ as well as educational inequities,⁴ which have led to more pronounced social disconnectedness and greater stress exposure (eg, academic challenges)-factors directly implicated in suicidal thoughts and behaviors (STB).⁵ Although substantial efforts are underway to improve the short-term prediction of adolescent and adult STB, limited research has focused on clarifying which preadolescent youth are at risk and when that risk is greatest.

Annotation (unstructured)

Auerbach, in their review of the work by Thomas et al, discusses the mental health crisis currently underway for preadolescent children. Auerbach identifies an understaffed and overburdened mental health workforce that can only accommodate high acuity care. Isolation, loneliness, stress, and experiences of educational inequities have contributed to a remarkable increase in suicidal thoughts and behaviors for preadolescent individuals; suicide is now the leading cause of death for children under 13 years old. Reviewing Thompson’s work, “across models, depressive symptoms, expressive suppression, rumination, and perceived burdensomeoness were associated with a greater likelihood of STB [suicidal thoughts and behavior].” Solutions, according to Auerbach, are multifactorial: first, a redoubling of effort in training and/or recruiting mental health professionals. Additionally, there is a need to improve children’s mental health literacy and, thereby, equip young people with language and skills to manage strong emotions. Given the dynamic nature of STB in preadolescents, Auerbach closes with a call to action to improve the capacity for longitudinal “intensive monitoring”, which they propose as the most effective means of facilitating rapid intervention in the event of a mental health crisis.