At the height of the pandemic, when everything was shut down, a patient with whom I had a long-term relationship developed suicidal ideation. A male adolescent who lived in poverty, he was not able to call me on his smartphone because he had run out of minutes. And he was ashamed to use his parents’ telephone because of privacy issues. Fortunately, he was able to find help.
I thought about him recently when my iPhone went into shutdown unexplainably for two consecutive Sundays at the same times and had to be erased each time. The good news was that I could still have used this bricked phone to call 911 in the event of an emergency. Any phone in the U.S. can be used to dial 911, regardless of whether it is currently registered with a cellular carrier.
The bad news is there was no similar option for me to call 988, the relatively new mental health emergency hotline.
Suicide is the second leading cause of mortality in youth ages 15 to 19 years in the United States. After the start of the Covid-19 pandemic, emergency room visits for possible suicide attempts began to increase in adolescents between the ages of 12 and 17 years, especially in girls. Additionally, data documented that suicide rates among people ages 10-24 rose significantly during 2018-2021, especially among Black people. A recent Trevor Project survey demonstrated upward trends of suicidal thoughts among LGBTQ+ adolescents.
The 988 hotline was developed not only for individuals with suicidal concerns, but also for those who are facing a mental health or substance use crisis. The 988 number should be a mandatory app on every smartphone used in America. And this app should be accessible regardless of whether the phone has minutes or is connected to a cellular network.
For more than a year, the 988 hotline has been functioning. But a recent poll conducted by the National Alliance on Mental Illness found that 82% of Americans were not familiar with it. Although the survey did not drill down into specific demographics, that percentage is almost certainly even higher for adolescents.
One problem might be that 988 deviates from the more familiar N11 codes. For example, there are codes for 211-911 that can be utilized from contacting community services to obtaining the locations of underground utilities. If 988 were a preloaded app on smartphones, then it would be readily apparent to the users. And if pressing on the app dialed 988, that would be extraordinarily helpful. When suicidal, adolescents may be restless, agitated, withdrawn, exhausted, or surprisingly calm. They may be using substances. When in a suicidal, mental health, or substance use crisis, adolescents may not be able to recall or tap out numbers.
Most smartphones have an emergency SOS feature that can be accessed from the power screen. With this feature, a call will be initiated with emergency services, but 988 is not included as an option. The SOS feature works even if the phone is not connected to a cellular network. 988 should be part of it.
Having an app labeled suicide hotline that only requires touch to activate 988 seems to be a reasonable option. It’s especially necessary for those individuals having a mental health crisis where they may have difficulty remembering or dialing 988. This app could be designed so that any user in possession of the phone could activate it easily. A 2018 Pew survey found that at least 95% of adolescents have access to a smartphone; the 988 app would be readily accessible to this age group.
There are, of course, some potential downsides here, but they are solvable. The user might mistakenly trigger the app. But this could be remedied by having a built-in pause or a go-ahead question before the call or text is made to 988.
One concern many people have had about 988 is caller privacy and safety. Ideally, with all 988 calls — whether it originates from my proposed app or from another source — counselors would be able to obtain the phone number of the caller (unless, of course, it is not currently registered to a cellular carrier, in which case it would be impossible to call them back) but not the geographic location. And the call should remain anonymous unless the caller decides to disclose identifying information.
Besides developing the technology for the app, there should be research to document those populations that have inadequate information about the hotline. And with this information, there should be outreach to those groups to increase awareness of this resource. And there should be capabilities for any smartphone to reach 988 even if the caller is not able to connect to a network. This should be the responsibility of all companies that design, develop, and produce smartphones.
After I reset my iPhone, I noted that it automatically came preloaded with an app for stocks. Pressing on this app shows data on the Dow Jones average and various stocks. If we can have an app for stocks, we certainly should have an app to prevent suicide.
Mark Goldstein is a physician and founding chief emeritus of the Division of Adolescent and Young Adult Medicine at Massachusetts General Hospital. He is currently writing a book with his spouse on contemporary issues in adolescence to be published in 2024 by the Oxford University Press.
If you or someone you know may be considering suicide, contact the 988 Suicide & Crisis Lifeline: call or text 988 or chat 988lifeline.org. For TTY users: Use your preferred relay service or dial 711 then 988.