COVID-19 and the National Suicide Prevention Lifeline

Content Warning: General, nonspecific discussion of suicide

On October 17, 2020, amidst a raging global pandemic and economic crisis, the President signed the National Suicide Hotline Designation Act of 2020 into law. This act created a 3-digit number to replace the current 10-digit number for the National Suicide Prevention Lifeline in 2022. Similar to 9-1-1, the new number will provide easy access to resources for people experiencing mental health crises ( National Suicide Hotline Designation Act of 2020 ).

The passage of this bill during the pandemic reflects the devastating impact of COVID-19 on mental health. Social isolation, loss, and financial struggles can lead people into despair and worsen their mental well-being. Indeed, the CDC reported that between April and June 2020, 40.9% of adults reported symptoms of anxiety or depression, a significant increase from the same period in 2019 ( Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020 ).

As a result, many mental health hotlines saw dramatic increases in call volume during March and April, as stay at home orders appeared around the country. The National Alliance on Mental Health's HelpLine service reported a 65% jump between March and April compared to 2019, and the Substance Abuse and Mental Health Service (SAMHSA) Disaster Distress Helpline saw an 890% spike in call volume in April compared to 2019 ( As calls to crisis hotlines spike amid the coronavirus, those who respond feel the strain ). It is clear that the early months of the pandemic led to an increase in mental health issues, but did these mental health issues also lead to an increase in demand for suicide resources? An analysis of the Lifeline may help reveal the answers.

The National Suicide Prevention Lifeline is a project of SAMHSA, a federal organization addressing issues related to substance abuse and mental health. The Lifeline is a centralized network of 180 call centers across the United States which can all be reached by dialing one number at  1-800-273-8255  ( Our Network ).

As the country's national suicide hotline, the Lifeline is one of the most widely-shared resources given to those seeking mental health support. Any Google search involving suicide includes an information box will provide the Lifeline phone number, and Apple's Siri refers users to the service if they express suicidality. Additionally, the Joint Commission on Accreditation of Healthcare Organizations requires all accredited organizations to give the Lifeline number to suicidal patients they are serving ( State Lifeline Reports ). The ubiquity of the service makes it a compelling indicator of greater patterns in suicidal ideation in the United States.

A 2019 report from the American Psychological Association stated that the rate of death by suicide in the United States increased by 30% between 2000 and 2016. Suicide is now the 10th leading cause of death, and a great tragedy on a personal and national level ( By the Numbers: An Alarming Rise in Suicide ). However, suicide doesn't impact all areas in the same way. Studies have consistently shown that suicide rates are higher in rural areas, and that suicidality disproportionately affects American Native and LGBTQ populations ( National Suicide Hotline Designation Act of 2020 ). Figure 1 below illustrates the suicide rate per 100,000 residents by state in 2018. It was created using the most recent data from the Kaiser Family Foundation, a nonprofit providing health-related statistics in the United States.

In 2018, the highest suicide rate was found in New Mexico, where the suicide rate was 25 people per 100,000. New Mexico was followed by Montana at 24.9, Wyoming at 24.8, and Alaska at 24.4. Suicide rates were lowest in the District of Columbia, New Jersey, New York, and Rhode Island.

Figure 1a, a hotspot analysis of Figure 1, reveals a cluster of high suicide rates in the Mountain West, and a cluster of low suicide rates in the Mid-Atlantic Region.

This distribution reflects the relationship with suicide and rurality. Although there is no consensus on why rates in the Mountain West are so high, some researchers have theorized that they may be related to high altitudes and a prevailing mentality of rugged individualism ( Suicide Rates on the Rise in Idaho, Mountain West ).

Figure 2, below, examines Lifeline call rates per 100,000 residents between April and June of 2020.

Note: This data does not include calls to the Veteran or Spanish Language Lifeline.

This data shows a few interesting similarities and differences to the 2018 suicide rate data shown in Figure 1. Here, Alaska has the highest rate of calls, with 228 calls per 100,000 residents. This mostly reflects its position in the 2018 suicide rate data in Figure 1. However, the second highest call rate was in Washington D.C., with a rate of 225 calls per 100,000 residents. In the 2018 data, D.C. had the lowest suicide rate, so it has nearly flipped its position when examining 2020 call volume. Call volume and suicide rate data are not necessarily correlated, but this remains a dramatic shift in placement. The other states with the highest call rates were Oregon and New Mexico.

To examine the data further, it is necessary to place it in context by comparing it to data from the same period the year before. Figure 3, below, shows the percent change in call volume from April-June 2020 compared to April-June of 2019. The data was calculated using the percent change formula on two datasets from the Lifeline, one from each year. Increases in call volume are represented in purple, and decreases in green.

On this map, the state with the greatest increase in call volume from 2019 to 2020 was Connecticut with a 27% increase, followed by Colorado, North Dakota, and Maine.

The state with the largest decrease was Alaska at 33%, followed by Rhode Island, Georgia, and Oklahoma.

The variety of data in this map may seem surprising, considering the stress of the pandemic and the increases in mental health problems reported by the CDC. Instead of showing across-the-board increases in call volume, about half of the states reported a decrease.

There are a number of reasons why this may be the case. Other hotlines have also experienced declines in call volume in some areas, notably domestic violence hotlines. Advocates for those hotlines have posited that the decreases in call volume may occur when people are quarantined with abusers and do not feel able to seek help ( The Health 202: Texts to federal government mental health hotline up roughly 1,000 percent ).

A report published in the British Medical Journal examined suicide rates in Western countries during the early months of the pandemic and found that there was either no rise, or a fall. The report described a phenomenon experienced in previous epidemics, where a short term decrease in suicide occurred near the beginning of the outbreak, possibly due to a "pulling together" phenomenon. Troublingly, the report described the illusions of this phenomenon by citing the situation in Japan, where suicide rates initially decreased by 20% early in the pandemic, but showed an increased of 7.7% in August ( Trends in suicide during the COVID-19 pandemic ).

More data in coming months and years may form a clearer picture of what caused these decreases in call volume during the early months of the pandemic.

The largest change between 2019 and 2020 was the outbreak of COVID-19, which was present in all 50 states at the end of June. Figure 3a overlays COVID-19 case data from June 30 onto the percent change information from Figure 3.

Looking at the map with COVID-19 case data overlaid, no relationship between case counts and change in call volume is immediately clear. However, stay at home orders and economic distress occurred across the country, so a state having a low case count doesn't necessarily mean that it was not impacted by the pandemic.

Some states did appear at the extremes of both statistics. Four states—Louisiana, Connecticut, Illinois, and New Jersey—were in the top 25% of both COVID-19 rates and percent change in call volume.

Five states—Alaska, West Virginia, Vermont, Oklahoma, and Idaho—were in the bottom 25% of both COVID-19 rates and percent change in call volume.

More data would be needed to explore the possibility of a relationship further. It is important to note that COVID-19, especially in the early days of the pandemic, hit hardest in urban areas, and we have seen that suicide rates are highest in rural areas. This inevitably impacts any relationship between case count and calls to the Lifeline.

For the Lifeline to properly serve residents of all fifty states, it is important that a state has enough local call centers to support its population. When someone in crisis calls the Lifeline, they are redirected to the call center nearest to them. However, if all the workers at that call center are busy, the caller will be redirected to a center in another state.

Redirections can be harmful, because a call center in another state may not be able to connect a caller with local, life-saving resources ( State Lifeline Reports ). Figure 4 shows two statistics: the population per call center in each state as of January 2021, shown in pink, and the rate of calls redirected out of state between April and June 2020, shown in blue.

Note: Population per call center was calculated by dividing population by the number of call centers in a state. This may not accurately reflect the state of affairs because different call centers have different capacities. A call center with 150 employees can serve far more people than a call center with 10. However, employee data was not made publicly available. Future investigations would benefit from including information on call center capacity in each state.

The state with the highest population per call center is Georgia, with one call center serving 10,390,390 people, followed by North Carolina, Texas, and Minnesota. The lowest population per call center is Wyoming, with one call center for every 299,166 people, followed by North Dakota, South Dakota, and Kentucky.

Wyoming had the highest redirect rate of 100%, followed by Minnesota, Vermont, and Wisconsin. In Wyoming and Minnesota, the call centers shown on the map were added to the Lifeline in August 2020, and thus were not taking calls from the lifeline between April and June ( State Lifeline Reports ). The state with the lowest redirect rate was Rhode Island, with a redirect rate of 1%, followed by Arizona, Maine, and California.

It is important to note that the Suicide Lifeline is not the only hotline in the US, and that many local hotlines operate independently of the Lifeline. However, because of the Lifeline's high-profile, national status, it is important that every state has enough Lifeline call centers to support its population.

Overall, data from the National Suicide Prevention Lifeline show mixed outcomes for change in call volume during the early months of the pandemic. About half of the states experienced increases of varying sizes in call volume, while about half showed a decrease. The amount of increase or decrease in call volume seemed mostly unrelated to COVID-19 case data. More data would be needed from later months to determine whether the declines in calls to the lifeline were an initial sinking due to the newness of the pandemic, or indicative of other factors.

The dataset presented here shows a snapshot of life during the first few months of the pandemic. However, the mental health impacts of the pandemic continue to devastate the country, and the service provided by the Lifeline is more important than ever. The data on local call centers indicates that many states have call centers with high redirect rates and service populations, meaning their callers may not receive the resources they need.

Because call centers rely on state and local contributors for funding, they require community support to stay active. You can support your local crisis center by  donating, volunteering, advocating, fundraising, and supporting on social media. 

Suicide is devastating, but there is always hope. In times of isolation, forming connections and reaching out to others is more important than ever. Suicidal ideation does not need to be a second, silent pandemic hidden by shame. Visit the  Suicide Prevention Resource Center  to learn how you can prevent suicide and save lives.

If you or anyone you know is experiencing thoughts of suicide, there is hope. Call the Lifeline at  1-800-273-8255  or reach out to the Crisis Text Line by texting HOME to 741741

Note: The author of this piece is unaffiliated with the National Suicide Prevention Lifeline or any other crisis hotline.