Concerns of Older Veteran Callers to the Veterans Crisis Line

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021)

OBJECTIVE

Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations.

METHODS

A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria.

RESULTS

Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding.

CONCLUSIONS

Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

Veterans Crisis Line Call Outcomes: Treatment Contact and Utilization

INTRODUCTION

Crisis lines are a central component of suicide prevention strategies in the U.S. and for the Department of Veterans Affairs. The purpose of this study is to evaluate the impact of calling the Veterans Crisis Line on treatment contact and utilization.

METHODS

Call records from 599 veterans who called in 2019 were linked with medical records and analyzed in 2020. Multilevel generalized linear modeling examined pre-post changes in treatment contact (yes/no) and utilization (number of days of care).

RESULTS

In the month after the call, 85% of callers made contact with health care, and 79% made contact with behavioral health care. Callers were more likely to make contact with health care in the month after the call than in the preceding month (AOR=6.27, 95% CI=4.22, 9.32) and more likely to make contact with behavioral health care (AOR=10.21, 95% CI=6.66, 15.67). Days of health care nearly doubled to 4.82, and days of behavioral health care more than doubled to 3.52.

CONCLUSIONS

Among veteran callers who are linked to medical records, calling the Veterans Crisis Line may increase contact and utilization of health care and behavioral health care. These findings support crisis lines that are linked with healthcare systems in public health strategies for suicide prevention.

Individuals who text crisis text line: Key characteristics and opportunities for suicide prevention

OBJECTIVE

Text-based crisis services are increasingly prominent, with inclusion in the national 988 crisis number launching in 2022. Yet little is known about who uses them. This study seeks to understand the population served by Crisis Text Line (CTL), the largest crisis text service in the United States.

METHODS

Secondary data analysis was conducted on de-identified Crisis Counselor reports, texter post-conversation survey responses, and anonymized text conversation data from 85,877 texters who contacted CTL during a 12-month period. We examined Crisis Counselor's ratings of suicide ideation severity, texters' reports of race, gender, sexual orientation, recent mental health symptoms, and additional sources of help, and logs of frequency of contact.

RESULTS

76% of texters were under 25. 79% were female. 48% identified as other than heterosexual/straight. 64% had only one conversation. 79% were above the clinical cutoff for depression and 80% for anxiety, while 23% had thoughts of suicide. 23% received help from a doctor or therapist, and 28% received help only from CTL.

CONCLUSIONS

CTL reaches a highly distressed, young, mostly female population, including typically underserved minorities and a substantial percentage of individuals who do not receive help elsewhere. These findings support the decision to include texting in the forthcoming national 988 implementation.

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

The Effectiveness of Crisis Line Services: A Systematic Review

Background: Crisis lines are a standard component of a public health approach to suicide prevention. Clinical aims include reducing individuals' crisis states, psychological distress, and risk of suicide. Efforts may also include enhancing access and facilitating connections to behavioral health care. This review examines models of crisis line services for demonstrated effectiveness. Methods: Literature searches of Medline, EMBASE, PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were conducted from January 1, 1990, to May 7, 2018. Experts were contacted, and references were mined for additional studies. Eligible studies provided health- or utilization-related effectiveness outcome(s). Results were graded according to the Oxford Centre for Evidence-Based Medicine and evaluated for risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. Results: Thirty-three studies yielded effectiveness outcomes. In most cases findings regarding crisis calls vs. other modalities were presented. Evaluation approaches included user- and helper-reported data, silent monitoring, and analyses of administrative records. About half of studies reported immediate proximal outcomes (during the crisis service), and the remaining reported distal outcomes (up to four years post-contact). Most studies were rated at Oxford level four evidence and 80% were assessed at high risk of bias. Conclusions: High quality evidence demonstrating crisis line effectiveness is lacking. Moreover, most approaches to demonstrating impact only measured proximal outcomes. Research should focus on innovative strategies to assess proximal and distal outcomes, with a specific focus on behavioral health treatment engagement and future self-directed violence.

Differences in Firearm Suicides by Residential Location in Texas, 2006-2015

This study used Texas state vital statistics records, 2006-2015, to examine firearm use rates among 28,010 suicide decedents by residential location (urbanized vs. all others). Firearms were responsible for 44% of all teenage suicides and 76-90% and 50-60% of suicides of men and women aged 60 + years, respectively, and firearm use rates remained steady for both genders during the study period. Logistic regression analysis showed a significantly higher firearm use rate (AOR = 1.35, 95% CI = 1.28-1.42) among decedents who resided in nonurbanized areas. Differences in firearm use rates by residential location likely reflect higher firearm ownership in smaller communities and rural than urban areas. The findings underscore the importance of community- and individual-level suicide prevention strategies.

Postmortem blood alcohol content among late-middle aged and older suicide decedents: Associations with suicide precipitating/risk factors, means, and other drug toxicology

BACKGROUND

This study examined blood alcohol content (BAC) among suicide decedents aged 50+ and its associations with suicide precipitating/risk factors, means, and other drug toxicology.

METHODS

The National Violent Death Reporting System, 2005-2015, provided data (N = 56,118 for all suicide decedents and N = 29,115 with alcohol test results). We used logistic regression models, with BAC > 0.0 (BAC positive) and BAC > = 0.08 (intoxication) as the dependent variables.

RESULTS

Almost a third of decedents who were tested for alcohol were BAC positive, and almost two-thirds of those who were positive had a BAC > = 0.08. Alcohol problems prior to suicide (AOR = 6.71, 95% CI = 6.24-7.21), relationship problems (AOR = 1.53, 95% CI = 1.44-1.63), and death/suicide of family/friends (AOR = 1.22, 95% CI = 1.11-1.35) were associated with greater odds of a positive BAC, but suicide means were not significantly associated with a positive BAC. Alcohol problems (AOR = 2.98, 95% CI = 2.68-3.31), relationship problems (AOR = 1.18, 95% CI = 1.06-1.30), firearm use (AOR = 1.85, 95% CI = 1.59-2.16), and hanging/suffocation (AOR = 1.38, 95% CI = 1.16-1.64) were associated with greater odds of a BAC > = 0.08. A toxicology positive for antidepressants, marijuana, cocaine, or amphetamines was associated with greater odds of a positive BAC; however, a toxicology positive for antidepressants, opiates, or amphetamines was associated with lower odds of a BAC > = 0.08. BAC > = 0.08 rates increased over the study period.

CONCLUSIONS

Alcohol intoxication may have contributed to using more violent suicide means. The significant association between relationship problems and intoxication before suicide calls for restricting access to alcohol and suicide means for individuals with these problems. Suicide prevention may require crisis counseling/support for acute life stressors and ongoing emotional support.

Older Suicide Decedents: Intent Disclosure, Mental and Physical Health, and Suicide Means

INTRODUCTION

This study examined: (1) associations of suicide intent disclosure with depressed mood and health problems; (2) age-group differences in those associations; and (3) relationship between disclosure and suicide means among suicide decedents aged ≥50 years (N=46,857).

METHODS

Data came from the National Violent Death Reporting Systems, 2005-2014. Data analysis was conducted in 2017. Chi-square tests were used to compare disclosers and nondisclosers on sociodemographic and precipitating factors and suicide means. Logistic regression analyses were used to examine the research questions.

RESULTS

The overall disclosure rate was 23.4%. Logistic regression results showed that both depressed mood (AOR=1.57, 95% CI=1.50, 1.65, p<0.001) and health problems (AOR=1.56, 95% CI=1.48, 1.64, p<0.001) were associated with increased odds of disclosure. Compared with decedents aged 50-59 years, those aged 70-79 years and ≥80 years had greater disclosure odds. When interaction terms of age group X health problems were entered in the model, disclosure odds increased among those with health problems in the groups aged 60-69 years (ratio of AOR=1.19, 95% CI=1.06, 1.34, p=0.003), 70-79 years (ratio of AOR=1.29, 95% CI=1.13, 1.48, p<0.001), and ≥80 years (ratio of AOR=1.41, 95% CI=1.20, 1.66, p<0.001). Compared with other suicide means, both firearm use and hanging/suffocation were associated with lower disclosure odds.

CONCLUSIONS

The older the decedents were, the more likely they were to have disclosed suicidal intent, and health problems largely explained their higher odds of disclosure. Healthcare providers need better preparation to screen and aid those in need to prevent suicide. Social support system members should also be assisted in identifying warning signs and linking older adults to services.