Crisis lines

Evidence Rating  
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Health Factors  
Date last updated

Crisis lines provide free and confidential counseling via telephone-based conversation, web-based chat, or text message to individuals in crisis, particularly those with severe mental health concerns such as suicidal thoughts. Crisis line counselors provide emotional support to callers, assess suicide risk, and refer callers to resources including counseling, social services, and emergency services. Counselors can be professionals or volunteers1.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Improved mental health

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Reduced suicide

What does the research say about effectiveness?

There is some evidence that crisis lines reduce suicide risk and depressive symptoms among callers2. Additional evidence is needed to confirm long-term effects2.

Assessments of crisis hotlines in the U.S. and the United Kingdom indicate that callers experience reductions in suicidal thoughts, self-harm ideation, distress, and hopelessness at the end of their call3, 4, 5, 6. A Denmark-based study shows that helpline text counseling services for children at risk of suicide appear to reduce distress, but the effects are only short-term7. Connecting youth at risk for suicide to crisis hotline risk management services has the potential to provide youth with information about coping strategies and sources of social support8.

An evaluation of an initiative of the National Suicide Prevention Lifeline (NSPL) that provides follow-up calls to high-risk callers and individuals discharged from inpatient or emergency department settings suggests that follow-up calls may reduce the risk of future suicide attempts9, 10. A Colorado-based pilot study indicates that crisis hotline follow-up calls for discharged suicidal emergency department patients may provide continued support and connection to outpatient care11.

Researchers suggest counselor training, integration with health care systems, specific services for vulnerable populations (e.g., lesbian, gay, bisexual, and transgender (LGBT) population), and creation of protocols for call monitoring and suicide risk screening are needed to increase crisis line effectiveness12, 13. Suicidal callers who speak to counselors with training in suicide interventions show greater reductions in suicide risk and depression over the course of a call than callers who speak to counselors without such training14. A crisis counselors’ safety planning intervention has the potential to reduce crisis callers’ future suicide risk15. A Canada-based study suggests that counselors with more experience, regardless of volunteer or paid staff status, appear to reduce suicide risk among callers more than counselors with less experience16.  

A survey of the NSPL suggests that 50% of those who call a suicide hotline and are referred to mental health services actually access those services1. An analysis of Crisis Text Line, a national text-based crisis service, indicates that rural counties have lower rates of service use than urban counties, while suicide risk in rural counties is higher than the risk in urban counties17.

How could this strategy impact health disparities? This strategy is rated no impact on disparities likely.
Implementation Examples

The National Suicide Prevention Lifeline (NSPL), funded by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), provides telephone-based hotline and online crisis chat services to anyone in suicidal crisis or emotional distress in 164 local crisis centers in 49 states18. The NSPL also provides follow-up services for callers to NSPL crisis centers as well as to suicidal patients discharged from hospitals; its “Follow-Up Matters” website offers follow-up guidance and toolkits for crisis centers and emergency departments19. SAMHSA’s Disaster Distress Helpline (DDH) offers trauma crisis counseling and support via call or text for those who experience mass violence, natural disasters, or infectious disease outbreaks20. Both NSPL and DDH have Spanish lines and provide interpretation services for more than 150 languages.

The Veterans Crisis Line (VCL) provides tailored crisis services for veterans and helps veterans’ families and friends identify signs of crisis and facilitate access to VCL21, 22. Crisis Text Line is a text-based crisis counseling service available across the country23. SAMHSA’s Native Connections program offers guidance on building a community-based suicide crisis response team for American Indian and Alaska Native youth, which includes crisis line support24.

Examples of local initiatives include the Crisis Support Services of Nevada, which provides telephone-based hotline and text message crisis intervention services 24 hours a day, and California’s Suicide Prevention Initiative, which offers telephone-based hotlines as well as web and text-based chat services12, 25.

Implementation Resources

NSPL - National Suicide Prevention Lifeline (NSPL). Together, we can change lives.

VCL - Veterans Crisis Line (VCL). Confidential help for veterans and their families.

CSSNV - Crisis Support Services of Nevada (CSSNV). Talk to someone now.

Crisis Text Line - Crisis Text Line. Support for teens, 24/7.

CDC-Coping - Centers for Disease Control and Prevention (CDC). Coping with stress.


* Journal subscription may be required for access.

1 Gould 2012 - Gould MS, Munfakh JLH, Kleinman M, Lake AM. National suicide prevention lifeline: Enhancing mental health care for suicidal individuals and other people in crisis. Suicide and Life-Threatening Behavior. 2012;42(1): 22–35.

2 Hoffberg 2020 - Hoffberg AS, Stearns-Yoder KA, Brenner LA. The effectiveness of crisis line services: A systematic review. Frontiers in Public Health. 2020;7:399.

3 Gould 2007 - Gould MS, Kalafat J, HarrisMunfakh J Lou, Kleinman M. An evaluation of crisis hotline outcomes. Part 2: Suicidal callers. Suicide and Life-Threatening Behavior. 2007;37(3):338-352.

4 Ramchand 2017 - Ramchand R, Jaycox L, Ebener P, et al. Characteristics and proximal outcomes of calls made to suicide crisis hotlines in California: Variability across centers. Crisis. 2017;38(1):26-35.

5 Tyson 2016 - Tyson P, Law C, Reed S, et al. Preventing suicide and self-harm: Evaluating the efficacy of a helpline from a service user and helpline worker perspective. Crisis. 2016;37(5):353-360.

6 Coveney 2012 - Coveney CM, Pollock K, Armstrong S, Moore J. Callers’ experiences of contacting a national suicide prevention helpline: Report of an online survey. Crisis. 2012;33(6):313-324.

7 Sindahl 2019 - Sindahl TN, Côte LP, Dargis L, Mishara BL, Bechmann Jensen T. Texting for help: Processes and impact of text counseling with children and youth with suicide ideation. Suicide and Life-Threatening Behavior. 2019;49(5):1412-1430.

8 Busby 2020 - Busby DR, King CA, Brent D, et al. Adolescents’ engagement with crisis hotline risk-management services: A report from the Emergency Department Screen for Teen Suicide Risk (ED-STARS) Study. Suicide and Life-Threatening Behavior. 2020;50(1):72-82.

9 Gould 2018 - Gould MS, Lake AM, Galfalvy H, et al. Follow-up with callers to the National Suicide Prevention Lifeline: Evaluation of callers’ perceptions of care. Suicide and Life-Threatening Behavior. 2018;48(1):75-86.

10 NSPL 2014 - National Suicide Prevention Lifeline (NSPL). Crisis Center Guidance: Follow-up with callers and those discharged from emergency department and inpatient settings. December 2014.

11 Catanach 2019 - Catanach B, Betz ME, Tvrdy C, et al. Implementing an emergency department telephone follow-up program for suicidal patients: Successes and challenges. Joint Commission Journal on Quality and Patient Safety. 2019;45(11):725-732.

12 RAND-Acosta 2017 - Acosta JD, Whitley MD, May LW, Dubowitz T, Williams M, Chandra A. Suicide prevention hotlines in California: Diversity in services, structure, and organization and the potential challenges ahead. RAND Health Quarterly. 2017;6(3).

13 Goldbach 2019 - Goldbach JT, Rhoades H, Green D, Fulginiti A, Marshal MP. Is there a need for LGBT-specific suicide crisis services? Crisis. 2019;40(3):203-208.

14 Gould 2013 - Gould MS, Cross W, Pisani AR, Munfakh J Lou, Kleinman M. Impact of Applied Suicide Intervention Skills Training (ASIST) on National Suicide Prevention Lifeline counselor: Interventions and suicidal caller outcomes. Suicide and Life-Threatening Behavior. 2013;43(6):676-691.

15 Labouliere 2020 - Labouliere CD, Stanley B, Lake AM, Gould MS. Safety planning on crisis lines: Feasibility, acceptability, and perceived helpfulness of a brief intervention to mitigate future suicide risk. Suicide and Life-Threatening Behavior. 2020;50(1):29-41.

16 Mishara 2016 - Mishara BL, Daigle M, Bardon C, et al. Comparison of the effects of telephone suicide prevention help by volunteers and professional paid staff: Results from studies in the USA and Quebec, Canada. Suicide and Life-Threatening Behavior. 2016;46(5):577-587.

17 Thompson 2018 - Thompson LK, Sugg MM, Runkle JR. Adolescents in crisis: A geographic exploration of help-seeking behavior using data from Crisis Text Line. Social Science and Medicine. 2018;215(July):69-79.

18 NSPL - National Suicide Prevention Lifeline (NSPL). Together, we can change lives.

19 Follow-Up Matters - National Suicide Prevention Lifeline (NSPL). Follow-Up Matters.

20 DDH - Substance Abuse and Mental Health Services Administration (SAMHSA). Disaster Distress Helpline (DDH).

21 VCL - Veterans Crisis Line (VCL). Confidential help for veterans and their families.

22 RAND-Acosta 2020 - Acosta JD, Cerully JL, Wong EC, et al. Veterans crisis line: Findings and recommendations. Santa Monica: RAND Corporation; 2020.

23 Crisis Text Line - Crisis Text Line. Support for teens, 24/7.

24 Native Connections-SRT - Native Connections. Building a community-based suicide crisis response team. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA); 2018.

25 CSSNV - Crisis Support Services of Nevada (CSSNV). Talk to someone now.