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"We should project our thoughts ahead of us at every turn and have in mind every possible eventuality instead of only the usual course of events." -- Lucius Annaeus Seneca

The launch of the 988 Suicide & Crisis Lifeline in July 2022 reminds us of the urgency of mental health crisis care. As a physician-scientist who has practiced emergency department psychiatry for decades, I would be interested to know what actually happens in these short, highly vulnerable moments immediately before and during crisis calls. Although this new entry point holds the potential for advancement in the field, and effectiveness of this new "comprehensive" crisis service continue to be raised and are likely valid.

More research is needed beyond general acceptance, case reports, some favorable numbers, and clinical anecdotal literature. Improvements to the lifeline are necessary to better understand local mental health needs, to evaluate the clinical expectations of intake counselors, to increase the visibility of existing resources, and to improve access where the primary barrier is clear and convincing pathology, not social determinants.

For example, there is no bias-free validity evidence demonstrating the crisis line's hypothesized efficacy in high-risk encounters. High-quality evidence demonstrating crisis line effectiveness during imminent risk of suicide . Furthermore, concerns regarding the thoroughness of crisis call counselors' specific assessment of risk utilizing the are significant.

On the one hand, it develops "nonjudgmental attitudes" and "...focuses not on the complexity of suicide and its causes, but on the simple concept and achievable goal of safety for now." However, in this prehospital setting, acuity must be determined by the patient's complaints at the intake dispatch level. As 988 counselors receive calls, they should not only identify a patient's acuity level through their complaints, primary symptoms, and comorbidities, but also route the call appropriately.

While 988 advisers may diligently answer high-volume calls, engage with non-emergent clients utilizing several communication preferences, and help devise a safety plan, it is the prioritization of calls and call-backs to address those with the most pressing needs that is particularly important. Without knowing what takes place during these calls or if there is any triage protocol in place, I'm at a loss over whether this resource is being appropriately deployed.

Callbacks

Callbacks must be performed within a specific window of time based on the initial triage evaluation of a person's complaint.

For example, crisis counselors should understand that some non-urgent callers who need help in a time of crisis may not answer a timely callback due to fear of police contact, stigmatization, involuntary hospitalization, or other severe personal or financial consequences from the call. In situations where individuals need immediate attention, the call should be transferred without delay to specifically trained triage counselors. In this way, the proper level of care can be customized. Unfortunately, with some stress-induced, rapidly progressive, often unobvious suicidal conditions, destructive behavior may occur during the crisis call itself or before the call-back is attempted.

Some proximal real-life traumatic events, imagined or threatened with unique personal salience or vulnerability, may expose persons to a singular and particularly life-threatening event for whom ASIST is not helpful -- no matter how the 988 hotline is currently used. This is descriptively termed extrapyramidal induced or autonomous suicidality with both motor and mental manifestations, and often characterized by the person's belief that they are in the process of dying (Latin, angor = distress, animi = animated).

This dynamic angor animi is equivalent to near-death, acute coronary persons gasping and in poor clinical status requiring heroic intervention. In the interval before irretrievable slowed reaction time, difficulty initiating and prioritizing tasks, and internal preoccupation occur, there is a therapeutic window through which the person may still be psychologically available and accessible by phone. But it will close rapidly. Immediate transfer to specifically trained triage counselors or prompt call-back is essential here.

Focused Factors

Beyond randomized trials or nonrandomized designs with some form of control to identify best assessment practices, only focused factors that influence outcomes of crisis conversations will begin to improve crisis care. The evaluation of focused factors of risk is complex but essential. Observational studies to examine effectiveness should also be conducted.

What represents a focused, goodness-of-fit factor of importance and survival in these highly vulnerable moments immediately before and during a crisis call? It is the early identification of seized neurocognitive capacity characterized by inhibition or loss of verbal or symbol fluency, i.e., phonological recoding to connect letters and numbers.

Enigmatically, it is the 988 string of numbers itself. Here's why it is important. During a psychological crisis, cognitive functions can be significantly affected. Acute stress can lead to mental slowing, impaired task switching, difficulty concentrating, reduced processing speed, and diminished comprehension.

Thus, for some during a disorganizing crisis, the 988 digital dialing code may not be an easy number to remember. Individuals in greatest need may not be able to access it cognitively at a certain point during their crisis. Therefore, the impact on the thoroughness of current, phenotype-specific risk training and assessment becomes essential with a pointed index of suspicion for unusual high-risk cases.

I understand the challenge and complexity. Identifying cognitive impairment is one thing, but then considering potential etiologies and intervening is a whole other thing.

Conclusion

It should now be obvious that suicide risk determinations require examination of intricate sensory processing. What is the requisite process? In simpler terms, these findings speak to the importance of crisis counselors, during initial call and timely callback, to suspect and understand rapid transitioning and autonomous suicide probabilities. Counselors must assess neurocognitive functioning, regardless of ideation, early and quickly in these crisis encounters. Well-timed tests of executive function, such as the 1-minute phonic alpha-numeric trail-making examination, are additional, easy-to-learn and easy-to-administer tools for the identification of risk acuity in a distribution of high-risk callers.

Future 988 training efforts and implementation need to focus on improving consistency and effectiveness of currently inadequate ASIST-like assessments of risk. In-depth training on focused factors, clinical guidelines, and suicide prevention strategies should be based on emerging high-quality evidence in the field of clinical usefulness. This should include empirical decision trees and differential diagnosis of extreme risk distribution phenotypes with intricate probability models.

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