This column discusses suicide. If you or someone you know may be struggling with suicidal thoughts, you can call 988 any time day or night, or chat online. Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they dial 741741.
In eastern Democratic Republic of Congo, I worked in a province of more than 6 million people served by a single public psychiatric hospital. More than 16% of that population had attempted suicide. When I describe this to American audiences, I get a sympathetic nod and a certain distance as they think, “That happens over there, not here.”
But the truth about the United States should unsettle us. About 137 million Americans live in a federally designated mental health professional
shortage area, and nationally we are meeting only 27% of the need. And, as of 2019, the last national count, 70% of rural counties had no psychiatrist at all.
We are not Congo. We have psychiatrists. We have simply built a country where they are not where people in crisis live.
Some things are working, like the national 988 hotline. Since launching in July 2022, it has taken more than 23 million contacts by call, text, chat and videophone. Roughly 8 million came in 2025 alone. That is a genuine achievement.
But a crisis system needs three parts:
- Someone to call.
- Someone to respond.
- And somewhere to go.
We built the first. The second exists in pieces. Congress created a Medicaid funding mechanism for mobile crisis teams in 2021, but most states still have not used it and more than half of the teams that do exist cannot cover a full day.
We need crisis walk-in centers, not ER and jail beds
When there is nowhere to go, the emergency department becomes the only option. Emergency departments are ill-suited to respond effectively to behavioral crises and tend to think in binary terms: Admit or discharge.
More people are admitted than need to be, and when more people compete for a few beds, the result is that the patient stays in the emergency department, sometimes in a hallway, sometimes in a locked observation room, waiting for a bed to open somewhere in the region. This is called boarding. Patients wait hours or days in a loud, bright room, stripped of their possessions.
The other scenario is that the police become the default, and the county jail ends up being the largest psychiatric facility in the region. This is more common than we would like to admit.
The piece that is missing is a crisis walk-in center.
The design is not complicated. It is open around the clock. Anyone can walk in, and police, fire and emergency medical services can drop someone off, regardless of acuity, with no wrong door. No appointment, no referral, no insurance required at the entrance.
Most people stabilize within a day and leave with medication, a plan, and a follow-up appointment instead of a charge or a hospital bill. Where these have been built, people mostly stabilize and go home the same day rather than wait for a bed.
Hospital-based versions have the strongest evidence: emergency stays cut by as much as 70%, inpatient admissions cut by more than 50%. Freestanding centers report similar results, though the research on them is younger and thinner. They also cost less, which is worth saying plainly to the people who write budgets.
We need more of these types of mental health urgent care and behavioral health crisis walk-in centers if the national answer to a suicidal crisis is going to be treatment rather than a wait.
How do I know when someone is close to suicide, and what do I do?
You often can’t know if someone is close to suicide, but sometimes you can.
Watch for someone talking about wanting to die, or about being a burden to the people around them. Watch for hopelessness stated as fact rather than mood. Watch for withdrawal, giving away things that matter to them, putting affairs in order or saying goodbye in a way that feels final.
Watch for a sharp increase in drinking or drug use, sleeping far more or far less, and agitation. Watch for sudden calm after a long stretch of despair.
These signs can sometimes cluster after a loss, a breakup, a firing, a legal problem or a public humiliation.
Then ask directly. Use the word. A review of the published evidence found no study showing that asking about suicide increases suicidal thinking, and the authors concluded that talking about it may reduce it.
The fear that we plant the idea is the single most durable myth in this field, and it keeps families silent at the exact moment their voice matters most.
If the answer is yes, do not leave. Listen without arguing them out of it. Call or text 988 together. Work with them and their clinician to reduce access to anything in the home that could be used for harm during a crisis, because these episodes can rise and fall in hours. A brief written safety plan paired with follow-up calls was associated with 45% fewer suicidal behaviors over six months compared with usual care.
Then check on them tomorrow, and the day after.
Tyler B. Evans, MD, MPH, DTM&H is cofounder and CEO of Wellness Equity Alliance and the author of "Pandemics, Poverty, and Politics: Decoding the Sociopolitical Determinants of Pandemic." He served as the first Chief Medical Officer for New York City's COVID-19 response and has worked in global health across dozens of countries for nearly three decades.
This article originally appeared on USA TODAY: 988 is a start. Now we need a place for people in crisis to go | Opinion
