Suicide Prevention Center of New York

Zero Suicide: Crisis Care for Everyone, Everywhere, Every Time

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David W. Covington, member of the Executive Committee of National Action Alliance for Suicide Prevention, begins a call for upgrading mental health crisis response systems in America with an analogy to a 2010 accident at a gold and copper mine near Copiapó, Chile.

Thirty-three miners became trapped nearly a half mile underground, but were brought safely to the surface after 69 days through an intense international rescue effort, Covington recalled in his presentation, “The Promise of 988: Crisis Care for Everyone, Everywhere, Every Time,” to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

“That obvious, caring, engaging, supporting, global collective impact and outreach has not been what we’ve seen for those whose darkness is not being trapped in a mine but having some kind of a mental health, substance use, or suicidal crisis,” Covington said. “For those individuals, it’s been far different.”

Covington’s presentation outlined the new vision for crisis care—“for anyone, anywhere, anytime”—that includes the introduction of the easy-to-remember 9-8-8 national phone number for the National Suicide Prevention Lifeline to assist people experiencing a mental health or suicidal crisis. Congress passed the National Suicide Hotline Designation Act in 2020 and the 9-8-8 number officially goes into effect in July 2022.

Part 7 in a Series about the Zero Suicide Model for Healthcare

The new vision for crisis care is reflected in the the National Guidelines for Behavioral Health Crisis Care issued in 2020 by the Substance Abuse and Mental Health Services Administration, Covington said. The guidelines, he added, stemmed from many efforts including the Crisis Now project of the National Association of State Mental Health Program Directors, developed with the National Action Alliance for Suicide Prevention.

Covington said the new model involves handling mental health crises with a minimum or total absence of police and hospital involvement—which the National Alliance on Mental Illness calls the “revolving door of ER visits, arrests, incarceration, and homelessness.” Rather, services are provided by mobile crisis response teams and non-hospital crisis care facilities.

Funding remains a major challenge for scaling up the new model of crisis care, Covington noted, with Congress looking to states to fund upgraded crisis services.

Covington said the new model for crisis care is in line with, and related to, the “extremely bold aspiration” of the Zero Suicide Model for healthcare, and is backed by a growing national momentum. “Let’s talk about how we might dare a much mightier system of care, and think about the way that we responded to those Chilean miners, without judgment, without shame. Instead, with an all-on full effort, an integrated and collective effort, to save their lives and support them, get them back to their lives,” he said.

The new model addresses what Covington called the “two sins” traditionally committed in crisis response.

The first, he said, is the message that reaching out for help leads to “punishment” in the form of a response by armed police officers. “Imagine that the darkness that you’re experiencing isn’t in a Chilean mine but in your living room in your apartment, and the response is law enforcement cars in the driveway, lights flashing,” he said. “About 70 percent of the time they’re handcuffed and placed in the back of the patrol car and transported to to a facility. While they may not in fact be arrested, it certainly feels like an arrest to the individual who’s in pain.”

The second sin, according to Covington, is “warehousing” individuals in a hospital emergency department as a way of handling individuals in crisis. He cited a 2013 Seattle Times report that found that in Washington State people in crisis arriving at hospital emergency departments were put into psychiatric boarding for an average of three days before getting access to mental health treatment. Some, the newspaper reported, waited for months.

“This is really hard for us to get our heads around, that this is the way we respond to people in a psychiatric emergency, in deep emotional pain, feeling suicidal,” he said. “We land up detaining them without real active care treatment for days, while they face the gauntlet of trying to get into a service. Many land up just falling through the bottom, falling through the cracks.”

Covington said the 9-8-8 hotline is an important step forward, likening it to the narrow opening that was drilled to make contact with the Chilean miners, to check if they were alive, and send them basic food and water supplies.

But, he said, “if 9-8-8 is all we do, then it’s going to be equivalent to those Chilean miners where we dig the four-inch diameter hole but we don’t actually get them out of that crisis, we don’t get them out of that hole. Many, many individuals will be supported through 9-8-8 and they won’t need more intensive services. But for those who need something more, making the connection is not enough.”

Covington said the new crisis care model envisions intermediate levels of support instead of the “red-light, green-light” approach that either directed patients toward the highest level of acute care or outpatient behavioral health care or follow-up care. He pointed to a flagship crisis response system in Arizona equipped with mobile crisis response teams and crisis care facilities.

“What a difference it makes when you have that approach,” he said. “Thousands of individuals are going directly into crisis care, and we’re reducing law enforcement engagement. You’ll see a much stronger fit of the level of service matching the clinical care they need. We haven’t eliminated psychiatric boarding in the Phoenix area, but we’ve reduced it by a staggering amount.”

Moreover, Covington added, “there’s a very significant reduction in overall healthcare spend as well as reductions in the exposure for hospitals. It’s an approach where care is much more like care than punishment.” The 9-8-8 number, providing an alternative for mental health crises to the 9-1-1 national emergency number in use since 1968, is an opportunity to reduce the involvement of police in the front end of a mental health crisis where there isn’t an explicit threat to public safety, he said.

Covington said the Community Mental Health Act of 1963, which provided federal funding for community mental health centers, never realized its promise.

“The challenges we face today as a result of the lack of that crisis system, the lack of that concerted engagement and outreach for those who are in pain or in darkness, are the extremely long waits in the emergency department, the extremely costly way that we go about this, concerns about the public safety of not having these systems in place, and far too many deaths that have occurred not only from suicide but from opioid overdoses, from alcohol related deaths, and other deaths that could have been avoided,” he said.

Covington said that innovations in crisis care began more than 60 years ago, with the first suicide crisis call center established in Los Angeles in 1958 leading eventually to the National Suicide Prevention Lifeline 1-800-273-8255 in 2005. He pointed to efforts in various states such as Georgia, Arizona, and Colorado to create unified systems of crisis response and care prior to the 2020 SAMHSA guidelines.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: Opening Pandora’s Box in Emergency Departments

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Edwin Boudreaux, professor of Emergency Medicine, Psychiatry, and Quantitative Health Sciences at the University of Massachusetts Medical School, advocates for universal suicide risk screening for patients entering a hospital emergency department.

The emergency department (ED), he said in “Zero Suicide Work in Emergency Departments: Opening Pandora’s Box,” his presentation to Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, presents an opportunity to identify and provide support for individuals at risk for taking their own lives.

He cited research indicating that some 40 percent of people who died by suicide had made an ED visit within the year, and mostly for reasons other than a personal mental health crisis. “A substantial proportion of them are being seen for a psychiatric crisis, but many of them aren’t and then they’re dying by suicide in the weeks or months after that visit,” he explained. “Is there something better we could do to try to detect that suicide risk prior to the person dying?”

Boudreaux also cited research showing that when ED patients were systematically screened, a larger than expected percentage indicated an elevated suicide risk due to recent suicidal ideation or a past suicide attempt.

Part 6 in a Series about the Zero Suicide Model for Healthcare

Bourdreaux himself led a universal screening study covering eight EDs across the United States. That study found that use of universal screening was feasible to implement, and that it detected suicide risk in 5.7 percent of patients compared to 2.9 percent in “treatment as usual” settings.

“The emergency department is a suicide risk environment, but we’re missing most of the patients who have suicide risk by using our existing approaches of just screening patients who are presenting with frank psychiatric symptoms,” Boudreaux said. “We demonstrated that it was feasible to do the [universal] screening and that when we did this improved screening we actually improved detection.”

Boudreaux called universal screening a “Pandora’s Box” because of a common fear among healthcare administrators that such screening could  challenge workloads and “break” the ED system. He said they worry about the lack of behavioral health providers, at-risk patient observers, boarding capacity, training for handling suicidal patients, and time required for making assessments. In addition, he said, administrators are concerned about creating patient dissatisfaction among individuals seeking ED services for non-mental health conditions.

“The biggest fear people have is, ‘What if I ask the question about suicide and they say yes. Then what do I do?’” he said. “The objection is it’s simply not feasible. There’s no way you can implement universal screening because it’s going to break the emergency department.”

For making the screening itself more feasible, Boudreaux pointed to Computerized Adaptive Tests, or CATS, a research-tested technological innovation in screening, and a CATS tool for youth known as the Computerized Adaptive Screen for Adolescents, or CASSY. He noted that traditional mono-dimensional quick-screen instruments like the C-SSRS Baseline Screening focus only on suicidal ideation and behavior. He said that CATS conducts screens quickly and with improved fidelity and efficiency, and also addresses multiple dimensions (such as depression, PTSD, suicidal ideation/behavior, and trauma history) yielding a spectrum analysis with more precise results and allowing a more complex risk formulation.

Boudreaux acknowledged the challenges of implementing universal screening in hectic EDs. He said that his study found that sometimes clinicians go through the motions of screening and mark a patient negative for suicidal thoughts without actually asking them the question.

Boudreaux argued that opening Pandora’s Box is do-able if EDs use their Clinical Decision Rules with the support of the CATS tool, and follow the Zero Suicide Model of efficient and appropriate pathways for suicide care.

“You have to establish a very clear protocol,” he said. “People can’t be confused or vague about what they do when they ask the screener and if they get a yes, or if they get a mild, moderate, or high risk. There can be no ambiguity. Your institution has to have very clear policies and procedures around the stratification of those patients and what happens. You can’t treat all risks the same. It’s a huge resource burden.”

He said for example, many patients screening positive for suicidal ideation do not need full psychiatric examinations or intensive safety precautions such as observation or boarding. He said that patients screening for mild risk could be given a referral to a behavioral health provider and educational materials to review.

Boudreaux highlighted the imperative that EDs understand the need for compassionate and evidence-based intervention that takes into account the patient’s values and preferences.

“They want respect,” he said. “Their idea of safety is treating is them with compassion. They want to feel like they can trust the clinicians who are working with them and not to overreact if they share that they’re suicidal and get the security guard involved and have to strip search them and admit them to an inpatient unit. It’s going to make them feel vulnerable. It’s going to make them feel traumatized, not safe.”

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: Best Practices for Primary Care

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Virna Little, Chief Operating Officer & Co-Founder of Concert Health, a national organization providing behavioral health services to primary care providers, trumpets the importance of preventing suicide in primary care.

Research shows that about 84 percent of people who die by suicide, and 92 percent of those who attempt suicide, had a healthcare visit within a year of their acts, Little said in her presentation, “Best Practices for Primary Care,”at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

Little also cited recent research indicating that people who died by suicide had suddenly resurfaced in primary care and became active on their healthcare portals within a month of their deaths.

Little spoke of her experience in conducting Zero Suicide trainings for 3,000 primary care providers in 27 states. She found that while 95 percent of the providers considered suicide prevention as part of their role, many of them were not trained either in their current positions or in their previous education. She found that many felt they did not have the knowledge or time to assess and intervene with an individual at risk of suicide.

She added that more than half of the behavioral health providers in these primary care settings did not feel comfortable or confident to care for someone at risk for suicide. She found that some people in her trainings were not familiar with the standard Patient Health Questionnaire that includes a key screening question about self-harm (PHQ-9).

Part 5 in a Series about the Zero Suicide Model for Healthcare

Little reported that many providers who had received traditional suicide prevention training did not feel it was helpful due to the trainers’ lack of understanding of how primary care practices operate.

“There are all kinds of places in primary care where people can fall through the cracks,” she said. “What I wanted to do was bring the idea of Zero Suicide and suicide safer care right to the front line, to make sure that we were doing something that would change what was happening in the primary care visit for people that were at risk for suicide.”

In her experience engaging primary care providers, Little said, they could easily identify their population of patients who suffered from diabetes but were usually silent when asked about how many of their patients were at risk for suicide.

Little felt that pediatric providers don’t really understand the extent of the problem of youth suicide. She cited data from the 2019 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention indicating that 8.9 percent of high school students in the survey had attempted suicide in the past year, and 18.8 percent had seriously considered taking their own lives.

In her training, Little urges primary care providers to adopt the seven core elements of the Zero Suicide Model, to bring a systemic approach to suicide care into their practices. Little stressed the importance of engaging everyone in a primary care practice, whether physicians and nurses or front desk and billing staff, in the process of suicide care.

“I often give an example of a practice where somebody cancelled three appointments within a very close time frame, and died by suicide,” Little said. “Nobody who answered the phone knew that she was at risk for suicide to do anything different. There was no process in place to catch that.”

Little’s training takes providers through the Zero Suicide protocols: effective screening procedures, speaking directly with patients identified as at risk, safety plans for patients, referrals to behavioral health specialists, and follow-up caring contacts.

She advises primary care providers to include suicidality on their patient problem lists, which provide immediately accessible structured data on their patients’ most important illnesses, diseases, injuries, or other health issues. “Imagine telling your primary care provider something really important, and then the next time you came in nobody even remembered,” she said.

Little said she also speaks with primary care providers about creating “pathways” of care for suicidal patients within their practice, and thinking about appropriate levels of  care so that suicidal patients are not automatically dispatched to hospital emergency departments.

“For example, everybody that comes in with chest pains, we would probably do an EKG, not everybody would go to the emergency room,” she said. “Not everybody who is asthmatic goes to the emergency room. So, one of our jobs in primary care is to make sure that people get the appropriate level of care.”

Little said that she found suicide care became more relatable when the primary care providers understood how discussing a patient’s suicidal thoughts with them and making referrals was little different than the usual workflows they use for patients with other issues like high blood pressure or asthma.

“Making those comparisons for primary care providers was incredibly helpful because it really helped them say, ‘Wait a minute you know what? I actually do this.’ I would remind them that, yeah, we shift gears all day long in primary care. It would be a beautiful day in primary care if somebody came in and they just had one thing going on and it was the actual thing that was the most urgent. If you’re going to engage primary care providers in this work, you have to speak primary care.”

She also said it was useful to provide primary care practices with role modeling for visits by individuals at risk for suicide, and to share storage statements with them that can be used to speak with such patients. She takes primary care providers through a role play of getting an at-risk individual to put the National Suicide Prevention Lifeline number in their phone contacts, or to access www.nowmattersnow.org, a website that shares stories of how people have coped with and survived painful emotions.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: Implementing the Model in Health Systems

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Brian Ahmedani, director of the Center for Health Policy and Health Services Research at the Henry Ford Health System, argues that a two-decade surge in the United States suicide rate underlines the need for greater efforts to prevent deaths by suicide.

“The suicide rate is the only cause of death right now in the U.S. that over the last 20 years has actually been increasing,” said Ahmedani in his presentation, “Implementing Zero Suicide in Health Systems,” at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.

“All of the other leading causes of death in the U.S. have annual rates that are either relatively stable or have actually been dropping pretty substantially over this period,” he said.

Ahmedani made the case for preventing suicide in healthcare by pointing to his own landmark research published in 2014 based on data from nearly 6,000 suicide deaths that more than 80 percent had seen a healthcare provider in the previous 12 months, almost 50 percent within a month, and more than 20 percent within a week.

Moreover, he said, the greatest number of individuals who died by suicide were not receiving mental health services, and more than half did not have a mental health diagnosis, pointing to the importance of using other healthcare settings such as primacy care practices to identify suicidal individuals.

“We really need to think about how we can put high intensity services in the settings where the fewest people go but who are at the highest risk, and then make sure that we also have low intensity services in those settings where there’s lots of people going to get care and most people are not at risk but where most people are touching before they die by suicide,” he said.

Part 4 in a Series about the Zero Suicide Model for Healthcare

Ahmedani credited the 2012 National Suicide Prevention Strategy for the landmark mandate determining that suicide prevention is a core responsibility of healthcare. He said that the Zero Suicide Model, developed at Henry Ford, took that mandate forward and provides the tools for a “golden era” of preventing suicide in healthcare.

At Henry Ford, he said, “We really focused on providing better care overall for our our patients and after doing that we saw a pretty substantial 75 to 80 percent reduction in suicide deaths over time in our in our health system. We were able to sustain that for almost 20 years now. You can think about all the numbers of lives that have been saved just because of that kind of care.”

He credited the development of many tools throughout the last 20 years, such as the PHQ-9 Patient Health Questionnaire, C-SSRS Baseline Screening, Brown Stanley Safety Plan, Dialectical Behavior Therapy (DBT), and Collaborative Assessment and Management of Suicidality (CAMS).

“This field is in its infancy stages, but yet we have all of the tools now,” Ahmedani said. “So we are in the opportunity phase of being able to implement those things into practice, and to use not only the knowledge that’s available from, and the structure that we developed at, Henry Ford, but also piggyback on all the research that’s been done across this entire time.”

“We also need the leadership and and the bold vision to push these things forward,” he added.

Ahmedani shared that Henry Ford is participating in three initiatives to further advance the Zero Suicide Model.

He said that Henry Ford and Kaiser Permanente are currently involved in a five-year study in six healthcare systems in Michigan, Washington State, Colorado, Oregon, and California covering 10 million patients a year to evaluate implementation of the Zero Suicide Model. The study is examining the health system metrics for driving implementation, fidelity to those metrics, and whether faithful implementation reduced suicide deaths.

A second initiative is a five-year comprehensive program to “revolutionize” suicide care within the Henry Ford Health System’s emergency departments, he said. It entails universal screening of every ED patient, risk assessments and safety plan counseling for positive screens, bridging referrals to behavioral health care through telehealth appointments with therapists, and post-discharge caring contacts.

Finally, Ahmedani said that through an initiative called MI-MIND, Zero Suicide processes are going to be implemented over the next few years in the five largest healthcare provider organizations across the state of Michigan in coordination with Henry Ford.

“We’re facilitating a suicide learning collaborative with healthcare systems that includes a monthly or a quarterly call to talk through their local implementation challenges, barriers, and opportunities, and work together as systems across the state,” he said.

“This is a model for going from one system, doing core implementation in behavioral health that spread to primary care, the emergency department, the hospitals, and all of our systems internally, to then spreading to new and revolutionized opportunities across multiple systems across the state,” he said.

“We have done this in Michigan, we have done this in different places across the state, and each of you have the opportunity to use this as a model to work across New York. Let’s let Michigan, let’s let New York, be leaders in the nation in suicide prevention.”

Ahmedani said that the Zero Suicide has been adopted by the national health systems or local health systems in more than 20 countries. “This this thing is growing like wildfire,” he said.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.

Zero Suicide: A National Perspective

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Richard McKeon, Branch Chief for Suicide Prevention at the Substance Abuse and Mental Health Services Administration (SAMHSA), highlights that Goal 8 of the 2012 National Strategy for Suicide Prevention encourages healthcare programs to “explicitly adopt the goal of Zero Suicide.”

Goal 8, McKeon noted in “A National Perspective on Zero Suicide in Healthcare,” a presentation to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, was reiterated in the U.S. surgeon general’s “Call to Action” issued in January 2021.

“The public and private sector looked at where we were in terms of suicide prevention and came to the conclusion that it wasn’t that we needed a new strategy but rather we needed to be vigilant about implementing the strategy that we have and the things that we know work and bringing them to scale,” McKeon said. “One of those things was Zero Suicide.”

McKeon reviewed the core components of Zero Suicide:

McKeon also outlined Zero Suicide’s “pathway to care” model:

  • Create a leadership-driven, safety-oriented culture
  • Develop a competent, confident, and caring workforce
  • Identify and assess risk, by screening and assessing
  • Provide evidence-based care, including a safety plan, restricting lethal means, and treating suicidality directly with proven therapies
  • Provide continuity of care

“There needs to be agreed upon guidelines for care, such as those that Zero Suicide provides, around identifying and assessing suicide risk, what the approach is for screening, and then for those who are identified as being at risk for suicide an approach to assessment, and that they have access to evidence-based care,” McKeon explained.

Part 3 in a Series about the Zero Suicide Model for Healthcare

McKeon pointed to the use of recent assessment and treatment tools, such as the PHQ-9 Patient Health Questionnaire, C-SSRS Baseline Screening, and the Brown Stanley Safety Plan; and to several therapies for treating suicidality directly: Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Collaborative Assessment and Management of Suicidality (CAMS), and the Attempted Suicide Short Intervention Program (ASSIP).

He highlighted restricting access to lethal means as a key evidence-based protocol of care that should be systematically adopted. He also noted that Zero Suicide protocols steer clinicians away from harmful practices.

 “For years, clinicians were relying on what were called ‘no suicide’ contracts because we weren’t providing them with anything better to utilize in working with people who were at high risk,” he said. “We know that ‘no suicide’ contracts were not only not effective, there was some evidence that they were counterproductive because patients in some sense accurately perceived they were more about the clinician or the system’s desire for protection from liability than it was about them and their pain. And of course it wasn’t effective to protect against liability, either.”

Another practice that Zero Suicide warns against, McKeon said, is directing healthcare clients to fill out a Patient Health Questionnaire that omits the question about suicidal thoughts and self-harm. “Dropping the suicide question is like putting on the medical chart, ‘If this patient is suicidal, we don’t want to know,’” he said.

Research supports the value of providing continuous contact and care for suicidal individuals, McKeon said. For example, he said that a survey of healthcare clients’ perceptions of care published by Columbia University researchers showed that 58.9 percent felt that follow-up phone calls helped “a lot” in stopping themselves from taking their own lives, and 21 percent said the calls helped “a little.”

“Ubiquitous and inexpensive technology is changing nearly every other industry,” McKeon said. “At a time when we can track a package halfway around the world, it should be unacceptable in the United States of America for us to lose track of people at high risk for suicide within the lethal gaps in many of our systems.”

McKeon said he understood why the idea of Zero Suicide has been controversial, with skeptics saying “we’re never going to be able to get there.” He said he empathized with a feeling among family members as well as clinicians who have lost loved ones or patients that Zero Suicide suggests that they should have been able to prevent the deaths. “That’s not at all what we mean, we sometimes talk about the preventability of suicide in too quick a way,” he said.

McKeon argued that Zero Suicide is an important goal representing “an assault on the fatalism around suicide that has held us back for many years, including in mental health components… What we mean is that no suicide is fated, no suicide is predestined, no matter how high the risk, until the person takes that final fatal step. There is always hope that they can be averted from that trajectory.”

A core belief of Zero Suicide is that the mission cannot be left to the efforts of an individual clinician but rather requires the dedication of the entire healthcare system, he stressed.

“When we say [suicide prevention] is a core responsibility of healthcare, it is really important that that’s not misinterpreted as the responsibility of individual clinicians,” McKeon said.

“For too long, but it is now changing with Zero Suicide, suicide prevention depended on the heroic efforts of individual clinicians or crisis staff, and many tried heroically to save lives and did save lives. But they were not backed up by a systematic approach within their system. It’s that systematic approach that really works.

“There’s a protocol for care for people who have been identified at higher risk, and there is consensus about how to assess the risk and about the treatments that can effective. That’s what Zero Suicide is about.”

McKeon outlined various other recent steps the federal government has taken to advance suicide prevention. He cited provisions in the 21st Century Cures Act of 2016 that authorized the National Suicide Prevention Lifeline into law for the first time and reauthorized the Garrett Lee Smith Memorial Act that provides grants for youth suicide prevention.

He outlined some of the progress being made in implementing Zero Suicide across the United States. He said SAMHSA has provided 35 Zero Suicide grants, and that implementation is underway in the Indian Health Service and the Air Force.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.