Modifying a 988 National Suicide and Crisis Lifeline Facilitation Intervention for Community Mental Health Clients with Serious Mental Illness

Background and Purpose: Suicide is critical public health problem in the United States and prevention efforts are particularly important for individuals with serious mental illness (SMI), namely bipolar disorder (BD) and schizophrenia spectrum disorder (SSD), who have a 20-30-fold increase in rates of suicide death as compared to the general population. Despite disproportionate rates of death and well-documented complexities of risk factors among individuals with BD and SSD, there is a paucity of suicide prevention-focused approaches with specific tailoring for symptoms of psychosis, depression, and mania. Crisis lines, such as the National Suicide and Crisis Lifeline (988 Lifeline), are a longstanding resource for suicide prevention with numerous national campaigns and initiatives aiming to grow public knowledge and utilization of the crisis line resource. Despite the 988 Lifeline being considered a CDC best-practice approach, national survey data show low utilization rates with only 5% of people in serious distress endorsing crisis line use. This study aims employ community-engaged methods to modify and test the acceptability, feasibility, and preliminary effectiveness of an existing suicide prevention intervention to increase 988 Lifeline use, Crisis Line Facilitation (CLF) and reduce suicide attempt, with specific tailoring for the unique symptoms of BD and SSD.

Methods: Stakeholders (n=20) participated in CLF modification efforts informed by the ADAPT-ITT framework,including clients with BD or SSD and recent suicide ideation or attempt, peer support specialists, mental health providers, and leadership in a community mental health (CMH) setting. All stakeholders attended a qualitative in-depth interview with research staff to explore perspectives on the need for CLF tailoring, implementation barriers, sustainability facilitators, and areas for intervention improvement. After transcription, qualitative data analysis was guided by domains of CFIR, involving content analysis to identify themes across qualitative questions for organization into a final framework.

Results: Qualitative themes largely pertain to intervention content, process of delivery, and organizational preparations for rolling out a new intervention in CMH. Findings informed modifications to tailor CLF content and protocol for BD and SSD symptoms for CMH clients, increase the feasibility of provider training, and inform the approach to embedding CLF in standard CMH care for SMI. A single-site trial is in progress to examine the preliminary effectiveness, feasibility, and acceptability of CLF among clients with BD and SSD.

Conclusions and Implications: Findings highlight the importance of tailoring suicide prevention-focused interventions for specific SMI symptoms and experiences. In addition, it is essential to tailor suicide prevention approaches for various clinical settings, such as CMH given they are among the largest mental health service providers in the United States and deliver the majority of SMI care. Testing the modified CLF intervention has potential for contribute to transformative change in suicide prevention efforts by increasing the intervention’s utility and usability in CMH and ultimately working towards reductions in premature suicide death.