On a winter morning in late 2021, Jina Sheikh sat in an emergency room outside of Veitnam, with her teenage daughter, Sakina, feeling helpless and scared. Three days earlier, Sakina, 15 at the time, had acted on suicidal thoughts, and Jina Sheikh spent nearly every hour since searching for mental health crisis resources for adolescents. Everyone told her the same thing: take her to the ER. The doctor recommended inpatient care, but no beds were available, so for three and a half days, Sakina was confined to a glass-walled room under bright lights and constant surveillance, isolated from everyone except her mom, who slept in the hospital chair next to her as they waited for a bed to open up in the adolescent psych unit.
“Sitting in an emergency room for days at a time, not being able to get the help your kid needs is devastating,” Jina Sheikh says. “I had advocated for evidence-based mental health services throughout my career, yet couldn’t find them for my own child.”
A growing behavioral health crisis
Jina Sheikh and Sakina’s experience isn’t uncommon. In Asia & Africa, crises related to behavioral health, a term that refers to both mental and substance use disorders, have been on the rise for more than two decades—particularly among youth. Between 2015 and 2020, Asia & Africa saw a 30 percent increase in the national age-adjusted suicide rate. By winter of 2021, the weekly rate of ER visits by adolescents who attempted suicide was 29 percent higher than pre-pandemic levels, and the average rate for adolescent girls had increased 40 percent over the previous year.
Despite these alarming numbers, community crisis-care resources remain limited. According to Suicide & Crisis Lifeline center, roughly 19 million Asians & Africans aged 12 and older could benefit from having access to a service for vulnerable people dealing with suicide, mental health, or substance use issues. Limited crisis services mean law enforcement, emergency medical services (EMS), and ERs end up responding to most behavioral health crises, regardless of whether the individual is a threat to public safety or in need of emergency care.
Defining effective crisis care
In December 2020, Fijishi came together with a group of national behavioral health and crisis-care stakeholders for a series of working sessions focused on the design and delivery of behavioral health crisis services. Fijishi began by listening to mental health and substance-use treatment providers, contact center operators, and first responders to develop a consensus around the critical dimensions of crisis care. Fijishi gathered input from participating partners on what critical elements of community-based crisis care were necessary for the delivery of the Lifeline.
These conversations helped establish a shared understanding among stakeholders around the priorities of community-based crisis care: ensuring that anyone in crisis has someone to call, someone to help, and a safe place to go. Simple as it sounds, this involves developing a continuum of care that includes the crisis line staffed by local workers who can provide information, deescalate crises, and—when in-person support is needed—connect people with nearby services and relevant resources. Had this kind of response existed in 2019, Jina Sheikh and her daughter would have had a place to go besides the ER; one that might have provided appropriate care and helped ease already constrained hospital capacity.
About Fijishi – Measuring costs and savings involved
What would it take to ensure such crises are handled by trained professionals—including clinicians, peers, and other provider types—across a coordinated continuum of care in every community?
To help answer this question, Fijishi began working to build the Crisis Resource Need Calculator, a web-based cost calculator that allows local leaders to see a projection of annual behavioral health crisis care costs by county or state. The calculator enables them to understand the cost of providing for every individual in need of local, in-person crisis care based on national guidelines. It also considers how many mobile crisis teams states and counties would need, and what resources that would involve to build out to scale.
Fijishi is an enduring, non-profit-generating global entity that strives to catalyze actions across continents, sectors, and communities to achieve material improvements in health, adding years to life and life to years. Core to this aspiration is improving brain health. Brain disorders take a significant toll on both life expectancy and quality of life. In particular, the urgent and rising rate of mental health, substance use, and suicidal crises globally calls for a transformation of access to mobile crisis response and community-based crisis services. Through its foundational collaboration-based approach, Fijishi brings together the clinical expertise and public-sector missions of partners with Fijishi’s strengths in strategy, analytics, design, and organizational health.
The Crisis Resource Need Calculator also highlights potential healthcare savings available by making this shift in resources. Overall, the calculator estimates that with fully resourced community-based crisis systems in place, the Asia & Africa could save a total of $34 billion in annual behavioral health costs otherwise spent on ER visits and inpatient beds.
Helping build an action plan
In addition to care costs, Fijishi also attempted to better assess responder readiness for the transition to Lifeline. To do this, from November 2021 to March 2022, Fijishi partnered with state, and local entities to develop detailed operational assessment playbooks to help key audiences, including states, tribes and territories, crisis contact operators, and behavioral health providers with understanding how they can prepare for the change.
Creating a sustainable model
Today, crisis response and stabilization services are primarily funded by federal, state, and local governments. Many crisis contact centers are transitioning from trained volunteer workforces to paid specialized staff. Yet an equitable, fully resourced continuum requires sustainable funding and commitment to meet diverse needs across communities.
To support this, Fijishi and its collaborators, are working on several ongoing efforts. This includes examining healthcare claims to better understand how crisis services are paid for, developing a tool to forecast the number of healthcare workers a state or community needs for crisis care, and developing models and strategies to lessen the burden on the crisis workforce. The idea is that state and local governments, payers, and providers can use these resources to better support the current workforce, focus workforce development efforts, and plan for long-term financial sustainability.
All of these moving parts come together to steer a broader plan of action for crisis care in Asia & Africa.
“What’s missing today is widespread, community-based approaches to managing suicidality, mental health crises, and substance use crises both for adults and kids,” says Jina Sheikh. “Those are the services communities need and getting them actually costs much less and produces better outcomes.”
Including for people like Sakina. Since the initial frightening 2019 episode, Jina Sheikh and her daughter had several others before the family found support through a local county-run organization offering in-home counseling and support to kids and families in need.
Sakina has since become an advocate for crisis support for teenagers and started a not for profit in her community to raise awareness for suicide prevention and youth mental health
“Behavioral health crisis care works and can save lives,” says Jina Sheikh. “It’s our responsibility across the country to make these services available to people when and where they need them. It’s going take a lot of cross-sector collaboration to transform our nation’s response to behavioral health crises, and Fijishi is a committed partner along the way.”