Introduction

Evidence suggests that community-based strategies such as mental health crisis hotlines play a crucial role in reducing user distress and preventing negative outcomes like suicides and violence (Balfour & Zeller, 2023; Hoffberg et al., 2020; Zabelski et al., 2023). Crisis lines effectively reduce immediate distress, with many users reporting decreased suicidal ideation following their interactions (Hoffberg et al., 2020). These services act as a lifeline for those with limited access to other mental health resources and have demonstrated the potential to stabilize individuals during emergencies, paving the way for the development of the 988 crisis hotline (Callaghan et al., 2024; Matthews et al., 2023; Zabelski et al., 2023).

The 988 Suicide and Crisis Lifeline, rolled out in July 2022, replaced the National Suicide Prevention Lifeline’s (NSPL) 10-digit number to streamline access to crisis support nationwide (SAMHSA, 2024). This 3-digit number aimed to enhance accessibility and address barriers exacerbated by the COVID-19 pandemic (Callaghan et al., 2024). Since its inception, the 988 crisis hotline has expanded multilingual support and tailored resources for select minority groups (SAMHSA, 2024). This expansion reflects a growing demand for accessible mental health services, with a reported 65.7% increase in hotline usage from its first month through July 2024 (SAMHSA, 2024). It’s important to note that prior to September 2022, all calls to the hotline were counted, whether callers were successfully connected to a crisis center or not. After that, only “routed contacts” — calls successfully connected to crisis centers — were counted (SAMHSA, 2024). Because the initial figures included all contacts, it likely overestimated successful connections, meaning the reported 65.7% growth in hotline usage understates the true growth in successfully routed contacts.

As the hotline passed its 2-year milestone in 2024, it is timely to evaluate its effectiveness, accessibility, and cultural competence in addressing mental health needs, to assess whether it is leading to equitable outcomes for underserved populations. In this review, effectiveness refers to the hotline’s ability to reduce distress, ensure timely intervention, coordinate seamlessly with other public service providers, and connect individuals to appropriate mental health follow-up care (Baker & Sorensen, 2024; Balfour & Zeller, 2023; Callaghan et al., 2024; Matthews et al., 2023; Pope et al., 2024; Zabelski et al., 2023). Accessibility reflects how easily diverse populations, especially communities of color, can utilize the service, addressing barriers such as language, technology, geographical constraints, and lack of awareness, while ensuring that historically marginalized groups feel safe and supported when utilizing the hotline (Baker & Sorensen, 2024; Balfour & Zeller, 2023; Callaghan et al., 2024; Pope et al., 2024; Zabelski et al., 2023). Cultural competence involves providing services sensitive to communities’ unique needs, delivered by responders trained in cultural humility (Pope et al., 2024; Zabelski et al., 2023). These terms —effectiveness, accessibility, and cultural competence —are critical for evaluating the 988 crisis hotline’s performance through an equity lens.

Despite notable advancements such as Spanish language services and specialized support for the LGBTQ+ population, considerable disparities remain (Zabelski et al., 2023). Communities of color and other historically underserved groups continue to face systemic barriers, including inadequate culturally competent training among responders and limited awareness of the hotline (Baker & Sorensen, 2024; Callaghan et al., 2024; Canady, 2024; Pope et al., 2024; Zabelski et al., 2023). These ongoing challenges highlight the need for a comprehensive equity-focused evaluation.

While previous systematic reviews have broadly examined the effectiveness of crisis hotlines (Hoffberg et al., 2020; Mathieu et al., 2021), none, to our knowledge, have specifically examined the 988 crisis hotline’s rollout through an equity lens. This systematic review synthesizes the findings from 9 studies on 988’s efficacy and public perceptions, determining whether it fulfills its promise to underserved communities and identifying strategies for improvement.

Methods

Search strategy and definition of terms

Following the PRISMA guidelines, a comprehensive systematic search was conducted between August and September 2024 to gather relevant literature on the 988 crisis hotline. The databases searched included PubMed, PsycINFO, and Google Scholar. The search aimed to capture a wide range of studies to ensure a thorough review of the available research. Additional context was provided by the Los Angeles Times, though this material was excluded from the primary studies analyzed.

The search used keywords from Medical Subject Headings (MeSH) to align with standard terminology in the field and subject. Three distinct sets of keywords were utilized and combined to refine the search results: 988-related services 1) “988” OR “988 suicide” OR “suicide prevention hotline” OR “crisis hotline” OR “mental health hotline” OR “mental health services,” population descriptors 2) “marginalized” OR “minority” OR “underserved” OR “diverse communities” OR “vulnerable populations,” and equity-related terms 3) “effectiveness” OR “cultural competence” OR “accessibility” OR “equity” OR “impact” OR “disparities”.

The first set of keywords targeted studies on the 988 crisis hotline and related crisis services, accommodating the limited availability of literature specifically focused on the 988 crisis hotline since its rollout in 2022. The second set aimed to capture studies referencing marginalized groups, accounting for the varied terminology often used to describe these populations. The third set of keywords broadened the scope of equity-related outcome descriptors of the 988 crisis hotline’s rollout, ensuring that studies aligned with the review’s objectives were not excluded due to terminology variations. The combination of these three sets of keywords allowed for a targeted yet comprehensive search, connecting the 988 crisis hotline to its implications for marginalized communities, specifically focusing on its effectiveness, accessibility, and cultural competence.

Eligibility criteria and data extraction

The search results were then screened based on predefined inclusion and exclusion criteria. We only included English language studies based in the United States and excluded studies that were 1) not peer-reviewed, 2) not related to the 988 crisis hotline or similar crisis intervention services, 3) published prior to 2022 (prior to the 988 rollout date), and/or 4) lacked empirical evidence or evaluations related to the effectiveness of the 988 crisis hotline. By applying these exclusion criteria, the systematic review aimed to ensure a focused and relevant analysis of recent and pertinent data on the 988 crisis hotline, reflecting its current efficacy and challenges.

The primary analysis of the studies was conducted by the first author, who identified and synthesized the key findings. Feedback was provided by the co-authors during the revision process to refine and validate the analysis.

Results

Study selection

Initially, a total of 172,000 studies were identified across multiple databases, including PUBMED, APA PsycINFO, and Google Scholar. After removing duplicates and refining results to English-language, U.S.-based studies published between 2022 and 2024, 17,500 studies remained. A preliminary screening of titles and abstracts for relevance yielded 23 records for full-text review to assess for eligibility. Of these 23 records, 13 were excluded as 11 records contained data analysis that predated the July 2022 rollout date of the 988 crisis hotline, 2 records were not peer-reviewed, and 1 record lacked empirical evidence on the hotline’s effectiveness or challenges. Ultimately, 9 peer-reviewed articles met the inclusion criteria and were analyzed for this systematic review. An overview of the search and screening process is shown in Figure 1.

Figure 1
Figure 1.PRISMA Study Selection Flowchart

Key Quantitative Findings

The reviewed studies provided key insights into the implementation and early impact of the 988 crisis hotline. A survey of 5,382 U.S. adults by Callaghan et al. (2024) found that only 25% were aware of the hotline shortly before its rollout, though over 75% indicated they would likely use it if needed. Matthews et al. (2023) surveyed 180 behavioral health program directors, representing jurisdictions with a combined population of 120 million. Fewer than half of respondents reported their jurisdictions were prepared for the hotline rollout in terms of financing (29%), service coordination (47%), staffing (41%), or infrastructure (41%). Counties with higher Hispanic/Latinx populations were particularly unprepared in these areas (Matthews et al., 2023). Pope et al. (2024) conducted 15 focus groups with 76 participants in New York counties. While participants anticipated using 988 for crisis support, many expressed concerns about law enforcement involvement, emphasizing the importance of clearly differentiating 988 from 911. Collectively, these findings highlight systemic barriers, disparities in preparedness, and the urgent need to build public awareness and trust in the 988 system.

Results of thematic synthesis

Three key themes were identified from 9 articles that met our inclusion criteria for this systematic review. These themes include (1) low awareness of 988 in communities of color, (2) insufficient cultural and linguistic competence in implementation, and (3) a need for better integration between public service providers aiming to address mental health needs in diverse communities.

To clarify each article’s contribution to these themes, a thematic mapping table was developed (Table 1). This table highlights how each study aligns with one or more themes, providing a comprehensive view of the research focus. While most studies directly addressed at least one theme, others, such as Purtle et al. (2023, 2024), contributed systemic insights that informed broader contextual understanding.

Table 1.Mapping Studies to Identified Themes
Study Low Awareness of 988 in Communities of Color Insufficient Cultural and Linguistic Competence in Implementation Need for Better Integration Between Public Service Providers Aiming to Address Mental Health Needs in Diverse Communities
Baker & Sorensen (2024) No Highlights the need for workforce expansion and strategies like expedited licensure and training of foreign-born clinicians to promote a culturally competent workforce. Discusses 988's crucial role in minimizing law enforcement involvement, decriminalizing mental health crises, and the need for coordinating with 911 and emergency services.
Balfour & Zeller (2023) No No Emphasizes the importance of seamless collaboration between crisis lines and law enforcement agencies.
Callaghan et al. (2024) Documents low public awareness before rollout, with vulnerable groups such as Black Americans being disproportionately unaware or unsupportive. No Highlights the role of law enforcement in mental health crises, emphasizing the need for integrated community-based mental health resources.
Canady (2024) Notes low public awareness and the tendency to default to 911 over 988 due to familiarity. No Highlights the importance of 988-911 interoperability, including training and shared protocols.
Matthews et al. (2023) Documents disparities in preparedness, with higher Hispanic/Latinx populations reporting significantly lower readiness for 988. No Emphasizes the need for service coordination, including 988–911 integration, strategic planning, and infrastructure.
Pope et al. (2024) Focus groups emphasized low public awareness. Identifies culturally competent training as a significant barrier to effective implementation. Explores the 988-911 relationship, focusing on public perceptions and the need for differentiation between the two systems.
Purtle et al. (2023) No No Highlights disparities in state-level funding models and their impact on 988 call volume and response effectiveness.¹
Purtle et al. (2024) No No Advocates for adopting 911-like financing models to ensure sustainable and equitable funding for 988 services.¹
Zabelski et al. (2023) No Highlights gaps in evaluating volunteers’ culturally sensitive performance, pointing to systemic deficiencies in culturally informed training. No

¹ These articles contribute systemic financial insights relevant to Theme 3, though they do not directly address thematic data from the reviewed studies.

Description of themes

Low Awareness of 988 in Communities of Color

Low Awareness of 988 in Communities of Color emerges as a prevalent theme in the studies, highlighting the urgent need to increase outreach efforts to these vulnerable populations (Callaghan et al., 2024; Canady, 2024; Pope et al., 2024). Overall, there was a notable lack of awareness across all groups. A cross-sectional study on public attitudes conducted just weeks before the rollout of 988 in June 2022 found that “roughly three quarters of Americans were unaware that the lifeline would soon be operational” (Callaghan et al., 2024, p. 479). Another study in New York, which examined participants’ expectations of the hotline, highlighted the “need for clear messaging at the local level about what 988 is—and what it is not” (Pope et al., 2024, p. 650). This widespread lack of awareness prior to the rollout of 988 can largely be attributed to what has been described as the line’s “quiet launch,” driven by limited resources for promotion and concerns about overwhelming the system with calls that exceeded its capacity in its early stages (Callaghan et al., 2024, p. 475). Strengthening public awareness is essential to ensuring that those in crisis can access and benefit from the critical support that the 988 crisis hotline aims to provide.

Although awareness of the 988 crisis hotline was generally low across all communities, studies highlight the disproportionate challenges faced by vulnerable populations in accessing the 988 crisis hotline, particularly those who are economically disadvantaged, have lower educational attainment, or lack consistent access to primary care (Balfour & Zeller, 2023; Callaghan et al., 2024). These systemic barriers, including inadequate insurance coverage, geographic constraints, shortages of culturally competent providers, and limited access to primary care, further restrict mental health service availability for economically disadvantaged populations (Balfour & Zeller, 2023; Callaghan et al., 2024). Communities of color in particular are among the least likely to be aware of or supportive of the hotline despite being at heightened risk for mental health crises (Callaghan et al., 2024). For instance, Black Americans were found to be “33% less supportive of the 988 crisis hotline compared to non-Black Americans” (Callaghan et al., 2024, p. 480) and are overall less likely to call for help during a mental health crisis (Balfour & Zeller, 2023; Callaghan et al., 2024). This hesitancy is often tied to fears and mistrust of law enforcement and the perception that contacting 988 may lead to police involvement, emphasizing the importance of clearly differentiating 988 from 911 (Baker & Sorensen, 2024; Balfour & Zeller, 2023; Callaghan et al., 2024). Given that the crisis hotline is often referred to as “the 911 for mental health,” it is essential to prioritize educating and raising public awareness on the differences between the two, particularly for historically marginalized and criminalized communities of color who may have valid concerns about engaging with the 988 crisis hotline (Balfour & Zeller, 2023, p. 21). Table 2 highlights key findings and quotes that illustrate this widespread lack of awareness and its impact on vulnerable populations.

Table 2.Low Awareness of 988 in Communities of Color
Theme Description Illustrative Quotes
Low Awareness of 988 in Communities of Color Awareness of the 988 crisis hotline is low among disadvantaged populations, exacerbated by limited promotion, unclear messaging, and disparities in local preparedness. “This lack of awareness may be attributable to what has been characterized as a ‘quiet’ launch for the 988 program (Messerly and Owermohle 2022) as a result of limited resources for promotion and concerns about a flood of new calls without sufficient capacity to handle them, and it could be reducing access to needed resources by those with mental health challenges.” (Callaghan et al., 2024, p. 485).
“Even if these hopes are aspirational, they reinforce the need for clear messaging at the local level about what 988 is—and what it is not. It is still not clear, for example, how the 988 system will handle calls that are deemed appropriate by the caller but that the call taker might consider too minor to handle (e.g., a caller who is having a ‘bad day’).” (Pope et al., 2024, p. 650).
“Vulnerable populations who are poorer, less educated, and without a regular source of primary care are the least likely to be aware of the 988 lifeline and therefore are less likely to benefit from the mental health resources it can provide. This could exacerbate existing disparities in mental health treatment and outcomes if it is allowed to persist.” (Callaghan et al., 2024, p. 485).

Insufficient Cultural and Linguistic Competence in Implementation

Another prominent theme in the literature is the Insufficient Cultural and Linguistic Competence in Implementation, which points to the inadequate culturally informed training, workforce, and assessment within the current 988 crisis hotline (Baker & Sorensen, 2024; Pope et al., 2024; Zabelski et al., 2023). Particularly, there is a significant gap in effectively addressing the unique needs of specialized and marginalized populations effectively (Balfour & Zeller, 2023; Callaghan et al., 2024). Although dedicated hotlines exist for groups like veterans, LGBTQ+, and Spanish speakers, recent studies reveal that these services often lack thorough evaluation concerning cultural sensitivity, equitable performance, and responsiveness to the diverse needs of these communities (Zabelski et al., 2023). This gap in evaluation raises concerns about the ability of the hotline to provide appropriate and inclusive care for individuals from culturally diverse backgrounds, highlighting the need for targeted improvements in training, workforce development, and assessment to enhance both service quality and accessibility (Zabelski et al., 2023). Table 3 provides a quote from the literature that highlights gaps in evaluation and training for volunteers, as well as the challenges in ensuring culturally sensitive and equitable responses for marginalized groups.

Table 3.Insufficient Cultural and Linguistic Competence in Implementation
Theme Description Illustrative Quotes
Insufficient Cultural and Linguistic Competence in Implementation Crisis hotline implementation lacks culturally and linguistically informed training and assessment, particularly concerning marginalized groups. “Moreover, although individual crisis lines that serve veterans, LGBTQ+ individuals, Spanish speakers, and people with impaired hearing exist, evaluation of crisis line volunteers’ culturally sensitive and nondiscriminatory performance is lacking.” (Zabelski et al., 2023, p. 509).

Need for Better Integration Between Public Service Providers Aiming to Address Mental Health Needs in Diverse Communities

Need for Better Integration Between Public Service Providers Aiming to Address Mental Health Needs in Diverse Communities emerged as another significant theme in the studies regarding the 988 crisis hotline, as the success of these services hinges on seamless collaboration and coordination with local agencies, particularly police departments (Balfour & Zeller, 2023; Canady et al., 2024; Matthews et al., 2023; Pope et al., 2024). Emerging findings from studies point to the need for collaboration and partnerships between police and mental health providers, especially as related to the 911 triggers of the 988 crisis line.

For the 988 hotline to be truly effective, there must be a strong and collaborative relationship between the local 988 operators and 911 operators and responders. While the 988 crisis hotline aims to minimize police involvement (911) in mental health crises (Balfour & Zeller, 2023), certain situations—especially those involving immediate threats to life—may still require law enforcement intervention (Pope et al., 2024). In these instances, close coordination and rapport between 988 operators and law enforcement can help ensure a mental health crisis is handled sensitively and appropriately, with a clear understanding of the context (Pope et al., 2024). This can include establishing clear protocols and strategic planning for when and how law enforcement should be involved in 988-related incidents, ensuring that the intervention is as least intrusive and as supportive as possible (Balfour & Zeller, 2023; Canady, 2024; Matthews et al., 2023; Pope et al., 2024).

Financial investment is a foundational element for fostering these collaborative relationships and ensuring effective integration (Baker & Sorensen, 2024; Matthews et al., 2023; Purtle et al., 2023, 2024). Purtle et al. (2023) demonstrated that disparities in state-level funding models contribute to variations in call volume rates and response effectiveness, highlighting the importance of equitable resource allocation. Similarly, Purtle et al. (2024) emphasized that adopting financing models similar to 911 could provide a sustainable foundation for 988 operations, enabling the development of robust partnerships with local agencies.

By working closely with local law enforcement, the 988 crisis hotline can also help build trust within communities, particularly in those where there may be a history of criminalization of mental health and negative experiences with the police (Baker & Sorensen, 2024; Balfour & Zeller, 2023; Callaghan et al., 2024). Researchers highlight in one study (Pope et al., 2024) how callers decide whether to call 988 or 911 during a mental health crisis and how their preference for a mental health hotline is influenced by fears of police brutality and lack of mental health training. Study participants expressed a preference for non-police responses, which could be perceived as “less traumatic” and “safer,” whereas police presence was perceived as potentially escalating tense situations (Pope et al., 2024, p. 649). The 988 crisis line was described by one of the participants in the study as a “ray of hope” that would not lead to the death or re-traumatization of someone experiencing a mental health crisis (Pope et al., 2024, p. 649). Transparent communication and coordinated efforts between 988 responders and 911 responders/police can reassure the public that their safety and mental health are being prioritized, and that law enforcement will only be involved when absolutely necessary (Balfour & Zeller, 2023; Pope et al., 2024). The interaction of 911 responses to 988 crisis calls warrants further research, especially within communities that have historically felt over-policed and unsafe with law enforcement. Financial investments, such as those highlighted by Purtle et al. (2023, 2024), are critical to establishing infrastructure, training, and shared protocols that ensure effective collaboration. Table 4 highlights quotes and findings that emphasize the importance of collaboration between 988 operators, 911 responders, and local agencies to ensure effective mental health crisis responses.

Table 4.Need for Better Integration Between Public Service Providers Aiming to Address Mental Health Needs in Diverse Communities
Theme Description Illustrative Quotes
Need for Better Integration Between Public Service Providers Aiming to Address Mental Health Needs in Diverse Communities Addressing mental health needs in diverse communities requires stronger integration and collaboration among public service providers, including 988 and 911. “In an ideal crisis system, robust interaction between 988, 911, and other crisis lines would occur so that calls can be appropriately triaged across systems, moving closer to a system in which there is truly no wrong door for receiving care.” (Pope et al., 2024, p. 650).
“At the local level, stakeholders must work together to create crisis systems that meet the needs of their communities, especially groups that have been historically marginalized and criminalized.” (Balfour & Zeller, 2023, p. 25).

Discussion

The 988 crisis hotline represents a significant advancement in mental health crisis intervention, yet this review identifies critical areas requiring improvement to ensure equitable outcomes. The themes of (1) low awareness of 988 in communities of color, (2) insufficient cultural and linguistic competence in implementation, and (3) a need for better integration between public service providers aiming to address mental health needs in diverse communities, highlight persistent challenges. Limited outreach and unclear messaging disproportionately affect Black and Hispanic populations, contributing to low awareness (Callaghan et al., 2024; Pope et al., 2023).

However, these challenges extend to broader underserved groups, where systemic barriers such as inadequate insurance, geographic constraints, shortages of culturally competent providers, and limited primary care access further hinder utilization and exacerbate disparities in mental health services (Balfour & Zeller, 2023; Callaghan et al., 2024). Even after the rollout, reports like Pope et al. (2023) emphasize the ongoing need for public education to clarify the hotline’s services and differentiate from traditional emergency lines like 911. Building trust between local police agencies and 988 teams, as noted in New York case studies, requires “strong intentional investment” in collaboration, particularly in vulnerable communities (Pope et al., 2023). These insights suggest that while the 988 crisis hotline has expanded accessibility, addressing the needs of diverse underserved populations, including those facing economic and geographic challenges, remains critical to reducing disparities and improving access to mental health care.

In addition to the challenges associated with the implementation of the 988 crisis hotline for marginalized communities, the articles reviewed consistently recommended several key areas to prioritize for future research to address existing barriers and improve the effectiveness of 988.

Ongoing Monitoring and Evaluation

The most prominent recommendation is the continuous need to refine and assess the 988 crisis hotline. Although the line represents a significant advancement in providing immediate support for individuals in mental health crises, the literature emphasizes that its long-term effectiveness remains uncertain (Baker & Sorensen, 2024; Balfour & Zeller, 2023; Callaghan et al., 2024; Canady, 2024; Matthews et al., 2023; Pope et al., 2024; Zabelski et al., 2023). The limited studies available suggest that while the implementation of the 988 hotline is a critical first step, on its own it is not a self-sustaining or comprehensive solution (Baker & Sorensen, 2024; Balfour & Zeller, 2023; Callaghan et al., 2024; Canady, 2024; Matthews et al., 2023; Pope et al., 2024; Purtle et al., 2023, 2024; Zabelski et al., 2023). Several studies highlight the need for regular monitoring, feedback mechanisms, and adaptations to ensure the hotline meets its intended goals (Pope et al., 2024; Zabelski et al., 2023). Particularly, one study found current research on cultural sensitivity and the long-term outcomes for users of crisis hotlines to be limited (Zabelski et al., 2023). This lack of research suggests that the current evaluation mechanisms may be insufficient.

Furthermore, another study highlighted the gaps in understanding whether the hotline adequately addresses the needs of its target populations and how individuals decide between using 988 versus 911 during a mental health crisis (Pope et al., 2024). Ongoing Monitoring and Evaluation should also address any notable discrepancies in current services, such as improving accessibility for diverse populations, expanding culturally informed training and assessments, ensuring follow-up care, and fostering effective partnerships with local law enforcement. These discrepancies highlight the challenges in delivering equitable and effective support through 988. Although the hotline marks a significant milestone in addressing our mental health crisis, particularly in response to the mental health challenges exacerbated by the COVID-19 pandemic, it remains in its early stages (Baker & Sorensen, 2024). Continuous tracking, dedicated research, and comprehensive evaluation are crucial for ensuring its long-term success and responsiveness to diverse community needs.

Table 4.Ongoing Monitoring and Evaluation
Recommendation Description Illustrative Quotes
Ongoing Monitoring and Evaluation There is a continuous need to refine and assess the 988 crisis hotline to ensure its effectiveness and inclusivity. “Research must keep pace with 988 implementation to ensure a detailed understanding of those whom 988 is serving, how 988 meets callers’ needs, whether it is possible to effectively transfer calls from 911 to 988, and the potential of 988 to connect people to a broad range of community-based services” (Pope et al., 2024, p. 650).
“Research into how and for whom the hotlines work has been scarce, including a lack of studies on hotline outcomes, the impact of hotlines on minoritized populations at risk for suicide, and whether volunteer training is effective and culturally competent.” (Zabelski et al., 2023, p. 510).

Sustained Adequate Funding

Second, Sustained Adequate Funding is essential to ensure the long-term effectiveness and broad accessibility of the 988 crisis hotline (Baker & Sorensen, 2024; Purtle et al., 2023, 2024; Zabelski et al., 2023). Stable and consistent financial support is critical to maintain and expand the hotline’s infrastructure, including hiring and training skilled crisis counselors, providing comprehensive cultural competency training, conducting ongoing thorough evaluations, upgrading technology, and equipping call centers to effectively handle call volumes over time (Baker & Sorensen, 2024; Purtle et al., 2023, 2024). A Los Angeles Times article emphasized the consequences of inadequate funding: “Too many states have neglected to establish a reliable funding source for 988 […] There’s more to be done to ensure that the lifeline is a reliable gateway to crisis care. No one is immune from a mental health or substance use challenge, and the demand for this care is rising” (Ingoglia, 2024, pp. 1–2).

Moreover, sustained funding is necessary to support public awareness campaigns, which play a vital role in educating the public about the 988 crisis hotline’s use and purpose. This is particularly important for disadvantaged and vulnerable communities that may be understandably hesitant to use the crisis hotline due to its perceived similarity to the 911 emergency number (Balfour & Zeller, 2023; Callaghan et al., 2024). Without sustained funding, the hotline risks becoming overburdened and under-resourced, which could hinder its ability to provide timely and effective crisis support (Baker & Sorensen, 2024; Purtle et al., 2023, 2024). Such limitations could weaken trust, particularly in communities already reluctant to engage with the service such as communities of color (Balfour & Zeller, 2023; Callaghan et al., 2024). To fully realize the potential of the 988 crisis hotline, it is imperative that federal, state, and local governments, along with key stakeholders, commit to long-term financial support. Ensuring this critical resource remains adequately funded is essential for its continued accessibility and effectiveness for all who need it.

Table 5.Sustained Adequate Funding
Recommendation Description Illustrative Quotes
Sustained Adequate Funding Significant, sustained funding is required to ensure the long-term effectiveness and broad reach of the 988 crisis hotline. “Sustained federal funding, and/or increases in state funding, earmarked for 988 Lifeline centers is likely important to ensuring that 988 Lifeline centers have the capacity to meet call demand in the post-988 implementation environment.” (Purtle et al., 2023, p. 2).
“The gaps in practice and research that have been identified are largely the result of underfunding of evidence-based practices and systems” (Zabelski et al., 2023, p. 510).

Continuity of Care

Continuity of Care highlights the critical need for ensuring follow-up services and ongoing support after the initial 988 call. While the 988 crisis hotline serves as a vital first point of contact for individuals experiencing a mental health crisis, this intervention works most effectively when it is linked with strong follow-up measures that ensure sustained care (Baker & Sorensen, 2024; Balfour & Zeller, 2023). Effective follow-up services after a 988 crisis hotline call, such as regular check-ins, referrals to professional mental health providers, and connections to community resources, are essential to prevent relapse or worsening of the individual’s condition (Balfour & Zeller, 2023). Without these measures, individuals may face deteriorating mental health, ultimately leading to higher costs and greater strain on the system (Balfour & Zeller, 2023). For those with complex or chronic mental health conditions, continuity of care ensures they remain engaged in treatment, helping them avoid falling through systemic gaps (Balfour & Zeller, 2023). Sustained support also helps build trust within communities, reinforces individuals’ well-being, and reduces the likelihood of future crises (Balfour & Zeller, 2023). Baker & Sorensen (2024) caution that “governments should not focus solely on addressing moments of crisis […] waiting until suicidal ideation or attempts occur to act is indicative of a system that has already failed its constituents. 988 will be a letdown—not a lifeline—if policymakers wait for suicide to act” (p. 10).

Although the primary metric for the 988 crisis hotline is the reduction of immediate distress following a crisis call, this captures only part of the hotline’s potential impact (Baker & Sorensen, 2024; Zabelski et al., 2023). Short-term outcomes, while critical, overlook the significance of long-term impacts. Measuring these long-term outcomes—such as sustained recovery, continued engagement with mental health services, and reduced suicidal ideation—can provide valuable insights for improving the 988 crisis hotline and ensure it delivers comprehensive support to the community (Baker & Sorensen, 2024; Zabelski et al., 2023).

Table 6.Continuity of Care
Recommendation Description Illustrative Quotes
Continuity of Care Emphasizes the need for follow-up services and ongoing care after a 988 crisis hotline call. “While the volume of calls and texts is encouraging, the potential for 988 to improve mental health care can only be effective if it operates in a linked fashion, not only providing a number to call, text, and chat but also services along a continuum of care.” (Baker & Sorensen, 2024, p. 2).
“There is a distinct lack of literature addressing the effectiveness of training for long-term caller outcomes and for other proximal outcomes […] Long-term caller outcomes that may be important for training, research, and evaluation purposes include the seeking of mental health services postcrisis, suicidal ideation over time, and use of crisis lines or services.” (Zabelski et al., 2023, p. 508).

This systematic review found that while the 988 crisis hotline represents a significant step forward in addressing mental health crises, its long-term success hinges on addressing several critical and formidable challenges. These include low awareness among communities of color, insufficient cultural and linguistic competence, and the need for better integration with public service providers – all of which require targeted, evidence-based solutions. Furthermore, the studies’ recurring emphasis on ongoing monitoring and evaluation, sustained adequate funding, and continuity of care highlights the importance of adopting a comprehensive approach to drive meaningful and lasting improvements. Ensuring the 988 crisis hotline’s long-term effectiveness requires not only addressing immediate crisis needs but also fostering trust, equity, and accessibility within mental health services. By prioritizing these areas in future research and policymaking, the 988 crisis hotline has the potential to evolve into a transformative and enduring resource for comprehensive mental health support.

Limitations

This systematic literature review provides valuable insights into the efficacy of the 988 crisis hotline but has several limitations. First, the limited data and research available since the hotline’s rollout in July 2022 may not capture recent developments or changes in its implementation. Second, many studies relied on cross-sectional data, offering only snapshots of public awareness and attitudes at specific points in time, with some conducted shortly before the hotline went live. This highlights the need for ongoing longitudinal research to assess the hotline’s long-term effectiveness. Third, regional variations in implementation may affect the generalizability of the findings. Future research should explore these regional differences, examining how local policies, resources, and practices influence the hotline’s efficacy. Fourth, while this review includes studies focusing on economically disadvantaged populations, it does not fully address the needs of all broader underserved groups. Additional research is needed to explore systemic barriers and equity outcomes for diverse populations, including those facing geographic and socioeconomic challenges. Finally, the review is limited by the absence of primary data, variability in study quality, and the potential for over-interpretation, as well as the challenge of comprehensively reviewing all relevant literature, despite a rigorous search strategy and predefined inclusion criteria.

Conclusion

The evaluation of the 988 crisis hotline rollout implications, synthesized from 9 articles, reveals a few key themes that are pivotal for its long-term success and equitable impact: (1) low awareness of 988 in communities of color, (2) insufficient cultural and linguistic competence in implementation, and (3) a need for better integration between public service providers aiming to address mental health needs in diverse communities. As highlighted in the literature, a lack of targeted outreach and culturally sensitive services remains a significant barrier to equitable access (Callaghan et al., 2024; Pope et al., 2023). Addressing these challenges requires an equity-centered approach, emphasizing inclusive research, increased funding, heightened public awareness, and culturally competent services inspired by successful initiatives. For example, Monroe County, New York, provides a valuable model for integrating 988 and 911 services while promoting cultural competence and public awareness (Pope et al., 2023). Through strengthened partnerships among call centers, mobile crisis teams, and 911 dispatchers, the county has effectively minimized unnecessary police involvement in mental health crises (Pope et al., 2023). Furthermore, targeted awareness campaigns and efforts to recruit culturally representative staff have built trust and improved accessibility for communities of color (Pope et al., 2023). While not without limitations, Monroe County’s approach provides valuable insights for fostering trust and equitable access in underserved populations.

By prioritizing equity-focused efforts, stakeholders can strengthen the 988 crisis hotline into a more sustainable and inclusive resource tailored to meet the unique needs of diverse and underserved communities. Future research and policy development should explicitly focus on measuring the hotline’s impact on long-term outcomes, such as sustained recovery and reduced disparities in mental health service utilization (Baker & Sorensen, 2024; Zabelski et al., 2023). This focus on equity will be pivotal in maximizing the hotline’s potential to provide accessible, culturally competent mental health support for all.