Yes, we need better crisis management, but what we really need is better crisis prevention.
During the past year, the COVID-19 pandemic has exacerbated the already severe substance abuse and mental health crises in the United States. Isolation and economic hardship have triggered spikes in depression, posttraumatic stress disorder, anxiety, and abuse of substances.
This unprecedented confluence of events, along with a welcome decrease in mental health stigma, has fueled a surge in demand for behavioral health services. According to a survey by the National Council for Behavioral Health (NCBH), more than half (52%) of community behavioral health organizations reported greater demand for services through August 2020, while half of organizations offering substance use disorder (SUD) services saw demand jump last summer.1
Unfortunately, many of these organizations are poorly positioned to meet this increased need for treatment services due to financial struggles. Nearly 65% of them have had to cancel programs, reschedule services, or turn away patients due to lack of revenue or pandemic-related restrictions. For some, the situation is dire: Nearly 40% of these organizations reported they may not last 6 months, given their revenue shortfalls.1
On top of patient demand and financial struggles, the disjointed and siloed crisis management infrastructure makes it difficult for individuals in crisis to receive the care and resources they need. Lacking access to appropriate behavioral health care, many in crisis turn to emergency departments (EDs). An analysis published in JAMA Psychiatry in February 2021 of nearly 190 million ED visits revealed that “visit rates for mental health conditions, suicide attempts, all drug and opioid overdoses, intimate partner violence, and child abuse and neglect were higher in mid-March through October 2020, during the COVID-19 pandemic, compared with the same period in 2019.”2
Even before the pandemic put an immense strain on the behavioral health care system, the Substance Abuse and Mental Health Services Administration (SAMHSA) was pushing for the standardization of crisis management across the US for any behavioral health condition.3
SAMHSA’s goal is to standardize care quality and care delivery processes based on the best evidence-based practices. In other words, we know what works and how to keep individuals out of the medical care and criminal justice systems. We now need to implement the right processes broadly. A key part of the infrastructure is a new number for the National Suicide Prevention Lifeline (NSPL), which is run by SAMHSA. A bill signed into law late last year designates the 3-digit code “988” as the new, easy-to-remember phone number for anyone in crisis trying to reach the NSPL.4
The 911 line currently is used for all emergencies, including mental health and substance use emergencies. But behavioral health crisis calls that result in the involvement of law enforcement sometimes result in tragic and traumatizing outcomes. In contrast, calls to the 988 mental health crisis number will be handled by trained NSPL counselors, who can in turn dispatch trained clinicians to a caller’s location. This behavioral health hotline number is expected to go live in July 2022.4
Providing a hard-to-forget number will not make much of a difference, however, if we are not able to standardize the quality of crisis care across the US. Currently, there are about 180 regional crisis lines that a caller could be patched through to, depending on area code.5 Those crisis lines offer varying degrees of services. Some are staffed by volunteers and non-clinicians who may lack experience and training, while others are staffed by veteran clinicians. Some can quickly connect callers to definitive assessment, treatment, and mobile crisis services. Others do not have these capabilities.
To address this challenge, in February 2020, SAMHSA released its National Guidelines for Behavioral Health Crisis Care Best Practice Toolkit.3 Aimed at behavioral health authorities, agency administrators, service providers, and state and local leaders, this document defines national guidelines for crisis care. It also offers tips for implementing care that are in alignment with national guidelines as well as tools to evaluate whether systems are aligned to those guidelines.
The guidelines published by SAMHSA lay out a vision for a no wrong door integrated crisis system in which, based on the caller’s needs, the appropriate type of care can be quickly identified and provided. Nobody is turned away. Elements of this system include a regional, clinically staffed crisis call center that provides multichannel intervention capabilities and quality coordination of crisis care in real time, a mobile crisis team that can reach any person in the service area, and short-term (23 hours) crisis facilities for receiving and stabilizing patients in a nonhospital environment.
SAMHSA is encouraging all states to set up this standard clinical infrastructure. The states will need the technology to coordinate clinical activity and provide situational awareness—this is where care behavioral-health-specific coordination tools come in. An example of such a tool includes a cloud-based software platform with real-time availability of inpatient and outpatient treatment services, connections to treatment and social support services, and evidence-based assessment tools. It is important to identify a solution that helps clinicians close the loop on their patients’ care.
Building Infrastructures for Prevention
These goals and guidelines for behavioral crisis management are welcome news. Yet some would argue that instead of spending time and money responding to crises, we should focus on prevention. The term crisis is not synonymous with prevention, but the goal of an end-to-end crisis system is to divert individuals from the inpatient beds and prisons, where they rarely get definitive behavioral healthcare. In addition, crisis systems provide preventative care: some of the data regarding crisis center calls shows that only 10% end up with a mobile team being dispatched to someone’s home. Of those calls, 80% are stabilized and do not require transfer to an inpatient care setting. Finally, of those who are transferred to a 23-hour crisis stabilization center, I estimate 75% are discharged home.
A very high percentage of the calls are being deescalated right on the line. But what then? With the right clinical and technology infrastructures in place, behavioral health crisis centers can refer callers to appropriate definitive assessment and treatment. In doing so, they can play a role in preventing callers from suffering a worsening of their current clinical condition, recurrence of this, or involvement with the medical care system and law enforcement.
To act in a preventative capacity, behavioral health organizations need technology infrastructure capabilities (Table). States have been awarded planning grants to set up the clinical and technology infrastructures for behavioral health management. But how do we ensure the states are effectively implementing their technologies and clinical workflows?
Creating a set of standard quality measures is a logical step. For example, the standard length of time it takes from call to mobile crisis team disposition could be set to a time interval, based on geography. If a team cannot meet that benchmark, there should be consequences. After all, taxpayers are giving states a lot of money to set up these systems. We need to know they are working. There is simply too much at stake.
Dr Rawat is Chief Medical Officer for Appriss Health, co-founder of OpenBeds, and an emergency medicine and critical care physician.
1. The National Council for Behavioral Health. COVID-19 continuing to impact behavioral health organizations in need of relief. Accessed June 29, 2021. https://www.thenationalcouncil.org/wp-content/uploads/2020/09/200903_NCBH_SCR.png
2. Holland KM, Jones C, Vivolo-Kantor AM, et al. Trends in US emergency department visits for mental health, overdose, and violence outcomes before and during the COVID-19 pandemic. JAMA Psychiatry. 2021;78(4):372-379.
3. Substance Abuse and Mental Health Services Administration. National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit. February 2020. Accessed June 29, 2021. https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf
4. Everett A. Groundbreaking developments in suicide prevention and mental health crisis service provision. Substance Abuse and Mental Health Services Administration. May 14, 2021. Accessed June 29, 2021. https://blog.samhsa.gov/2021/05/14/groundbreaking-developments-suicide-prevention
5. National Suicide Prevention Lifeline. Our network. Accessed June 29, 2021. https://suicidepreventionlifeline.org/our-network/