Understanding mental health risk in Aotearoa: an analysis of the 1737 Need to Talk telehealth service

Globally, mental or substance use disorders (as described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) are common, impacting the lives of many across the globe.¹ Most disorders (62.5%) first occur before the age of 25 years, with the peak age of 14.5 years, making early recognition and intervention essential.² Experiencing mental illness—including depression and anxiety—is a risk factor for suicide.³ Overall, suicide rates in New Zealand decreased by 20% from 1996 to 2016; however, not all demographic groups reflected a decrease.⁴ New Zealand has been identified as one of the five Organisation for Economic Co-operation and Development (OECD) countries (alongside Lithuania, Finland, Ireland and Chile) with the highest suicide rates for young people (15.6 per 100,000 15–19-year-olds).⁵ Between 2015 and 2019, the leading cause of all mortality in 15–19-year-old New Zealanders was suicide. Māori males had the highest rates of suspected suicide, with a rate of 23.9 per 100,000, 1.4-times higher than non-Māori males. Suspected suicide rates for Māori peaked in 2019–2020 at 21.0 (per 100,000 Māori), compared with the New Zealand average rate of 12.9 (2019–2020). The age group with the highest suspected suicide rates was the 20–24-year age group, which peaked in 2018–2019 at 25.8 per 100,000.⁶

For those experiencing high-risk mental health conditions, telehealth services provide critical and timely access to mental health professionals and, where necessary, connection to emergency services, without the barriers associated with traditional support. The 1737 Need to Talk service provides a mental health support service to 5.3 million New Zealanders, 24 hours a day, 7 days a week, using a free-to-call phone and text number, publicly funded by Te Whatu Ora – Health New Zealand.⁷ The line is staffed by trained telehealth peer support workers or counsellors, who use a call flow plan to build a rapport with the service user, identify their presenting issue and develop a plan with the service user focussed on making a behaviour change or using their usual coping strategies, to build their resilience.⁸ In the case of immediate risk of harm—including risk of suicide—to a service user or another person, risk is assessed, and a plan developed that may include immediate referral to local crisis services. Where a plan cannot be agreed on and risk is serious and imminent, the “Break Glass” procedure allows the call handler to contact emergency services (police or ambulance) without requiring the consent of the at-risk service user (New Zealand Health Information Privacy Code).⁹

The aim of this research is to describe the utilisation of the 1737 Need to Talk telehealth service (mental health call and text helpline) in New Zealand. We describe the patterns of 1737 contacts over time and describe the contact users, including the most at-risk contacts (defined as those contacts who trigger the “Break Glass” procedure).

Methods

Study design

This is a retrospective observational cohort study using routinely collected demographic and Break Glass data from the 1737 Need to Talk service. Data from 1737 Need to Talk service users was collected between 1 June 2017 and 31 December 2022 (5 years and 7 months).

Setting

The 1737 Need to Talk telehealth service is a free service that commenced in June 2017, providing 5.3 million New Zealanders with a platform to call or text message when they feel anxious, overwhelmed by emotions and/or thoughts, depressed and in need of support. 1737 Need to Talk is one of the 37 free telehealth services that Whakarongorau Aotearoa makes available to all New Zealanders.¹⁰ The service provides free 24/7 support utilising a “one-off intervention with an open door to return” model of care.⁸ Service users are given the option of either counselling or a peer support service; the latter is provided by people with lived experience of their own mental health or addiction challenges. Through the 1737 Need to Talk service, the counsellor or peer support worker builds rapport with the service user, establishes the problem for which they are seeking help and develops a support plan based on their immediate needs or situation.⁸

In the event of a service user being at risk of harming themselves or others, or if a child is at risk, a safety plan is developed with the service user, which may also involve “warm transfer” to the local mental health crisis team or emergency services. A warm transfer requires the call handler to talk to the service user and then the service they are being transferred to before connecting the two on the phone and ensuring they are talking before disconnecting. However, where a plan to ensure safety cannot be agreed and there is a serious risk of harm, the Break Glass procedure is followed. A Break Glass procedure is initiated in the event of a service user having high-risk physical health needs, being a risk to themselves, a current/future risk of harm to others (including child abuse/neglect) and/or they have disclosed past serious harm to others and are at risk of re-offending (2020, Whakarongorau Aotearoa Internal staff document).

Ethics

This research project was approved by the Auckland University of Technology Ethics Committee (AUTEC) (23/28). STROBE cohort reporting guidelines were followed. Service user data were provided in a de-identifiable form.¹¹

Participants

The data included in this research project involved service users who called or texted the free 1737 Need to Talk service. For this research, 1737 Need to Talk total contacts refer to the number of calls and text conversations the service receives. The total number of 1737 Need to Talk contacts includes unanswered calls; however, unanswered calls were not included in the service user data. 

Variables

De-identified data collected at the time of contact were provided by Whakarongorau Aotearoa for all service users. During the conversation, the call handler would note the time of call and ask the caller for their demographic details including gender, age and ethnicity group (as identified by service user) (prioritised)¹² and New Zealand district (previously known as district health boards). Population data by New Zealand district is available through StatsNZ.¹³ Deprivation data for each of the health districts was obtained from the New Zealand Index of Multiple Deprivation (IMD18).¹⁴

Study size

Between 1 June 2017 and 31 December 2022, there were 719,904 contacts to the 1737 Need to Talk helpline and 3,089 Break Glass incidents recorded.

Statistical methods

Both the number of offered 1737 contacts and the proportion of 1737 Need to Talk contacts that resulted in the Break Glass procedures were calculated by month. A linear regression model was used to analyse the trend over time, using the month as the independent variable and the number of contacts/proportion of Break Glass incidents as the dependent variables, with R² indicating the goodness of fit. Comparative analyses for gender, age and ethnicity were performed based on the relative proportions of Break Glass service users compared to all 1737 Need to Talk service users using the Chi-squared test. A t-Test was used to compare the district data for Break Glass and 1737 contacts rates per 10,000 people to the New Zealand national averages.¹³ A linear regression was performed using the IMD18¹⁴ for each district as the independent variable and the 1737 utilisation or Break Glass data per 10,000 as the dependent variables, with R² indicating the goodness of fit. R and RStudio were used for statistical analysis.¹⁵ Differences with p-value (p) <0.05 were deemed statistically significant.

Results

Between June 2017 and December 2022, there were 719,904 contacts: 421,367 (58.5%) contacts by call, and 298,537 (41.5%) by text messaging. Of these contacts, 49.9% were from unique users, with an average of 10,745 contacts per month or 353.3 per day (Appendix Table 1).

1737 Need to Talk text and call contacts by month and year

View Figure 1–6.

The year with the greatest number of contacts was 2021 (170,532), while the busiest month was April 2020 (17,699). The total number of 1737 Need to Talk contacts increased in a polynomial trend with time, with an R² value of 0.8997 (Figure 1). Peaks in contacts to the services were observed around major events in New Zealand (the Christchurch mosque attack and COVID-19 lockdowns) (Figure 1).

Break Glass incidents by month and year

A total of 3,089 Break Glass procedures were applied between 2017 and 2022, with an average of 46.8 Break Glass procedures applied monthly (Appendix Table 1). During this period, the average proportion of Break Glass incidents compared to offered 1737 contacts was 0.43%, ranging from 0.20–1.15%, excluding the introductory month of June 2017 (Figure 2 and Appendix Table 1). Linear regression testing proved a significant increase with time for the proportion of calls resulting in a Break Glass incident compared to total contacts (p<0.05). However, this increase is low—an estimated increase of 0.0021 in Break Glass incidents compared to total contacts per month. The period with the highest number of at-risk contacts was seen in 2022, with 952 Break Glass incidents (30.8% of the total).

Break Glass incidents by gender

There was a significant difference in gender proportions for 1737 Need to Talk contact rates vs Break Glass incidents (p<0.001; Figure 3, Appendix Table 2 and Appendix Table 3). There is an over-representation of females in contacts where the Break Glass procedures were initiated: of the total 3,089 Break Glass procedures followed, 1,978 (64.0%) were as a result of calls from female service users (whereas females accounted for 53.7% of 1737 Need to Talk contacts), 691 (22.4%) were from males (males accounted for 25.6% of 1737 Need to Talk contacts) and 48 (1.6%) were from service users who identify as gender diverse (overall, 1.1% of 1737 Need to Talk contacts identify as gender diverse) (p<0.05; Figure 3 and Appendix Table 2).

Break Glass incidents by age group

The highest number of Break Glass incidents were regarding 13–19-year-old service users with 819 (26.5%) incidents, followed by 20–24-year-olds with 419 (13.6%) incidents (Figure 4; Appendix Table 4). While 13–19-year-olds account for 15.1% of contacts (the highest of all age groups), they still have a significantly higher proportion of Break Glass procedures initiated (26.5%; p<0.001). Significant over-representation in Break Glass procedures was also found for 20–24-year-olds (p<0.001), 30–34-year-olds (p<0.01), 45–49-year-olds (p<0.001) and 55–59-year-olds (p<0.05). Interestingly, 82.4% of youth under 20 contacted the service through text messaging, compared to 45.0% of service users aged between 20 and 64 years and only 7.5% of those aged 65 and older.

Break Glass incidents by ethnicity

A significantly higher proportion of Break Glass incidents were observed compared with their 1737 Need to Talk contact proportion for NZ European (43.7% compared to 41.7%; p<0.05) and Māori (13.2% compared to 9.0%; p<0.001) ethnic groups (Figure 5). There is a large proportion of unknown service users (>37%; Figure 5).

Break Glass incidents by New Zealand district

There were regional differences in the number of 1737 Need to Talk contacts during the study period (Figure 6, Appendix Table 6). The New Zealand national average was 714.7 contacts per 10,000 people, with Auckland city (1,216.9), Canterbury (1,071.1), Capital & Coast (896.8), MidCentral (826.0), Southern (861.8) and Whanganui (982.7) all reaching levels significantly above the national average (p<0.05; Figure 6, Appendix Table 6). Lower utilisation of the 1737 Need to Talk service compared to the national average was observed in Bay of Plenty (470.4), Counties Manukau (522.8), Lakes (518.1), Taranaki (550.0), Wairarapa (478.4), and Waitematā (472.6) (p<0.05; Figure 6, Appendix Table 6). While one of the main urban centres—Auckland city—had the highest utilisation (1.7 times the national average use per 10,000 people), the two other regions covering the Auckland region had below average utilisation (Counties Manukau and Waitematā).

There were also regional differences in the number of Break Glass procedures followed (Figure 6, Appendix Table 6). Whanganui and MidCentral districts (which border each other) had the highest number of Break Glass incidents per capita, with 14.39 and 11.46 per 10,000 people, respectively. From 1737 Need to Talk contacts per capita, the districts with the highest contacts were Auckland city and Canterbury, with 1,216.9 and 1,071.1 contacts (per 10,000 people), respectively. The Whanganui, MidCentral, Nelson Marlborough, Waikato and Canterbury districts were statistically higher than the New Zealand average of 5.18 Break Glass incidents per 10,000 people (p<0.05; Figure 6). Conversely, Bay of Plenty, Counties Manukau, Northland, Tairāwhiti, Wairarapa, Waitematā and West Coast all had significantly lower rates of Break Glass incidents per 10,000 people than the New Zealand average (p<0.05; Figure 6).

Break Glass incident data were compared with New Zealand district deprivation data.¹⁴ Linear regression analysis revealed no significant relationship between New Zealand deprivation ranking and 1737 Need to Talk utilisation (R²=0.063) or activation of the Break Glass procedures (R²=0.015) (Appendix Table 7).

Discussion

Between 2017 and 2022, there were 719,904 contacts to the free 1737 Need to Talk service, 3,089 of which were from at-risk service users defined as the application of the Break Glass procedures (accounting for less than 0.5% of 1737 Need to Talk contacts). The Break Glass incidents have remained relatively stable over this time, despite fluctuations in overall demand for the 1737 Need to Talk service. Service users most at risk (activating the Break Glass procedures) were found to be of the female gender, in the 13–19-year-old age group, and those residing in Whanganui and MidCentral districts.

Our data suggest that there has been an increase in the number of service users presenting to the 1737 Need to Talk telehealth service. Specific peaks in contacts to the 1737 Need to Talk telehealth service correlate with significant events in New Zealand at the time. On 25 March 2020 and 17 August 2021, New Zealand went into a Level 4 COVID-19 lockdown (the most restrictive) where only essential workers could travel to work, and New Zealanders were required to remain at home.¹⁶ Other significant events correlating with a prominent peak in contacts include the Christchurch terrorist attack on 15 March 2019,¹⁷ and the terrorist attack in September 2021 in Auckland.¹⁸ Our findings suggest that New Zealanders engage with freely available mental health support in times of significant need. The 1737 Need to Talk telehealth service offers the advantage of being free and available 24/7 by text or call. While in-person consultations can pick up on non-verbal cues and may be preferred by some service users, they can also be daunting for those who find it challenging to speak to someone (in-person), and potentially financially prohibitive and challenging to access.¹⁹ The year-by-year increase in the number of people reaching out to 1737 Need to Talk could in part reflect the increasing awareness of the service, in particular in response to the widespread advertising of the service following the Christchurch mosque terrorist attack and through the COVID-19 lockdowns.^16–18,20 Our data suggest that there has been a small growth in the number of service users presenting at risk over the past 5 years and 7 months.

Females were significantly over-represented in Break Glass incident data. The utilisation of the Break Glass procedure is consistent with New Zealand data showing that there was a 132% increase in self-harm hospitalisations from 2016 to 2021, with females comprising 78% of these hospitalisations in 2021.²¹ The over-representation of females in the Break Glass cohort is consistent with research demonstrating that females are at increased risk of mental distress.²² Additionally, males are also less likely to reach out for mental health support when in need.²³

Māori and NZ European ethnic groups were disproportionately over-represented in Break Glass incidents compared with all contacts to the 1737 Need to Talk telehealth service. However, caution should be given due to the large proportion of unknown ethnicity data and the relatively small number of Break Glass events.

There were significant variations in the utilisation of the 1737 Need to Talk service across New Zealand. Further research is needed to determine whether these fluctuations reflect differing mental health demand, or whether the communities are as informed about the availability of the 1737 Need to Talk service. Concerningly, Whanganui and MidCentral, neighbouring districts, have rates more than double the New Zealand average for Break Glass (2.8 and 2.2 times, respectively). No significant correlations could be found with New Zealand Index of Deprivation (NZDep) or suicide data. This discrepancy suggests that suicide risk is not the main or only factor contributing to a Break Glass procedure through the 1737 Need to Talk service. One theory is that this could be due to the high rates of family violence in these regions, with one in 10 calls for help to the police concerning family violence reported for Whanganui.²⁴ It is, however, likely that there are multiple factors that contribute to these Break Glass district data.

Adolescents (13–19 years old) are disproportionately represented in this data as presenting with serious risk (i.e., Break Glass), at almost double the proportion of the next highest age group of young adults (20–24-year-olds). This youngest age group preferentially reaches out by text, a medium that is used increasingly as a tool for delivering mental health support and services to young people.²⁵ The increased complexity through text messaging could be reflected in the high number of Break Glass incidents observed for this age group. Adolescents have the highest rates of first onset of several mental disorders, including obsessive compulsive disorder (14.5 years), eating disorders (15.5 years), anxiety (5.5 years and 15.5 years) and substance disorders (19.5 years). Schizophrenia and mood and personality disorder onset peak slightly later at 20.5 years old; these mental disorders correlate with critical brain development stages.²⁶ This study was unable to record the proportion of LGBTQIA+, a group with high rates of mental illnesses.²⁷

Since 2012, the mental health needs of New Zealand adolescents have shown significant increase across all demographics, particularly females, Māori, Pacific peoples and Asian ethnicities, and those residing in areas of high deprivation.²⁸ International literature has also shown significant increases in the number of mental health concerns for youth (12–17 years) and young adults (18–25 years), especially in females.^29,30

Limitations

Limitations of this research include the secondary use of clinical data collected primarily for continuity of care and clinical audit. The use of prioritised ethnicity data—where only a single ethnicity is counted, may under-represent some ethnic groups. Where text messaging is concerned, one contact involves multiple text messages back and forth, meaning each message only results in multiple contacts if they occur on different occasions. Individual contacts refer to the number of (unique) individuals using the service. This research does not detail the specific symptoms that triggered a Break Glass incident. As these data values are relatively low, due to the high proportion of missing data for some user characteristics as a result of the anonymity of service users included in this research, these results should be interpreted with caution.

Conclusion

This study has detailed the monthly trends and demographics of service users who contacted the all-hours, freely available 1737 Need to Talk service (between 2017 and 2022) and those users deemed most at risk through the Break Glass procedure. The number of Break Glass incidents has remained consistent, whereas contacts through the service appear to have plateaued towards the end of the analysis period. This research identified the most at-risk service users in New Zealand for each demographic: the female gender, the 13–19-year-old age group, and the Whanganui and MidCentral districts. This research supports the need for ongoing mental health support for these at-risk demographics to prevent increases in Break Glass incidents. Whakarongorau Aotearoa leverages technology to provide the safe, easily accessed 1737 Need to Talk service in an increasingly complex environment when the workforce is stretched and more New Zealanders are seeking support.

View Appendix.