Executive Summary

Shout is a free text messaging service, available 24 hours a day, 7 days a week to anyone in the UK who is struggling to cope. Since its launch in May 2018, Shout has scaled rapidly, conducting nearly 2.5 million conversations by April 2024. This is a significant achievement, demonstrating the valuable role that Shout plays in supporting people with their mental health needs, often in times of crisis.  

Using data and insights provided by Mental Health Innovations (MHI), and research and analysis by the Institute of Global Health Innovation (IGHI) at Imperial College London, this report examines how people access Shout. The work was supported by a Service User Voice Group (SUVG), comprising a diverse group of people with experience of using Shout to help them cope with mental health difficulties. 

Our analysis shows that Shout is addressing an unmet need. Based on a survey of Shout texters, 43% said they do not access NHS or other public mental health services for support. Middle-aged men and people under 25 – groups who are particularly susceptible to poor mental health and suicide – were least likely to access support from other services. Of those who did access support from other services, only 6% strongly agreed that they found them easy to access. 

People with certain health or demographic characteristics are particularly likely to access Shout. For example, around 1 in 5 texters surveyed reported having autism, and around 2 in 5 texters identified as LGBTQ+. These rates are many times higher than the wider population in England, demonstrating Shout’s value to people who may feel underserved by existing services. People whose preferred language is not English were less likely to access Shout. 

Insights from our interviews, user survey feedback, and data analysis show that Shout is valued because: 

• It supports people who seek help out of traditional working hours, when other services or support networks are not available to them. 
• It supports people who prefer texting, as it allows them time to process their emotions, and to easily refer back to advice and signposting in their conversation history. 
• It provides a safe space, enabling people to silently receive support without fear of being overheard, and without needing to provide identifiable information or formally entering the NHS system. 

Overall, people who access Shout feel better for doing so. Analysis of data provided by MHI shows that: 

• 83% of texters said that they found their conversation helpful 
• 66% of texters said they felt calmer  
• 59% of texters said they could work out their problems better. 

Since the service began, Shout has developed more than 38,000 safety plans for people whose lives were at risk, and intervened with the support of emergency services on nearly 33,000 occasions.  

MHI is committed to building on the opportunities identified by this report. This includes, for example, a project to better understand the preferences of 10-13 year olds, and the development of a new service to provide bookable one-off sessions between peer volunteers and young people. MHI will also consider how it can match volunteers to texters with specific knowledge or lived experience – such as LGBTQ+ or cultural or ethnic communities – while still protecting their anonymity.  

A key concern raised by the analysis in this report is the scale of the challenge to meet the mental health needs of people in the UK. MHI is continuing to explore opportunities to increase its capacity, such as using paid crisis practitioners to provide consistent support during nighttime hours when more traditional services are unavailable. However, sustainable solutions will require a whole system approach, with the broad range of services necessary to continuously improve mental health care across the UK.   

2. Access to Shout 

2.1 Addressing a gap

​​Based on data insights provided by MHI in May 2024, Shout is filling a gap for texters that is not currently met by most public services. 43% of texterssay that they do not access NHS or public mental health services for support with their mental health. ​Middle-aged men​​​​​ were the least likely to be accessing support from other services (54%), followed by young people (aged 24 and under) (47%) – these are groups who are particularly vulnerable to poor mental health and suicide. 84% of texters agreed or strongly agreed that Shout should be funded to support more people with their mental health.​ 

The profile of people who contacted Shout during 2023/24 highlights its use by people with certain health characteristics or from certain demographic or socio-economic backgrounds:   

• 19% of texters identified as autistic, many times more than the estimated population of 1-2% of the population in England.  
• ​21% reported that they had Attention deficit hyperactivity disorder (ADHD), significantly higher than the estimated prevalence in England, of 3-4% of the population. 
• 41% identified as LGBTQ+, with 9% identifying as non-binary or transgender. This compares to an estimate of 3% and 0.5% respectively across England and Wales. 

​Of those who access other support for their mental health from the NHS and public services, 22% were currently accessing support, 20% had accessed support in the past, and 15% were on waiting lists for support. Of those currently accessing, ​​or who have previously accessed, support:  

• Only 6% strongly agreed that it was easy to access, and middle-aged men (age 45 to 64) were most likely to strongly disagree (3​4​​​%).
• 28% felt they could get the support they needed, and middle-aged men were most likely to disagree or strongly disagree (56%).
• 67% agreed or strongly agreed that Shout filled a gap in support that other NHS and public mental health services struggle to provide. People with ADHD or autism and people identifying as LGBTQ+ were most likely to agree or strongly agree with this statement.

Respondents were asked what NHS and public mental health services they use for support with their mental health, showing a range of options from charitable or private services to NHS services such as Child and Adolescent Mental Health Services (CAMHS), NHS talking therapies or NHS mental health teams and their GP. ​​ 

When texters were asked what ​​gap they thought Shout fills in support for mental health, a common theme was that Shout offers support during times of crisis, 24/7. Some people said they did not know of any other 24-hour service, and even though they might have to wait for a reply, this was nowhere near as long as having to wait for other support (e.g. NHS). Around a third of respondents felt that Shout provides texters with someone who they can talk to, who will listen to them, and who will help them cope in the short term. Some people said they appreciated the non-judgemental support from volunteers who truly listen to their problems, which they cannot find elsewhere. People described how Shout can help bring them down from crisis point or prevent them from getting there. 

Some texters felt that Shout offers help and support when other services or support networks are not available. A number of people said that Shout works particularly well as an out of hours service, or a service providing in-the-moment support, whereas therapy may be more long-term. Several people said they were not considered “bad enough” for other services, and without Shout they may have ‘fallen through the cracks.’ A number of texters felt that Shout was easier to use for support as they could text and not talk. Some people said this was because it was late when they needed support or their circumstances at home prevented them from speaking. Others described how they found it easier to text as they were autistic or had other needs that made this form of communication easier.  

A smaller number of respondents said they liked the anonymity of Shout, talking to someone who does not know them. This also had the advantage, for some, of getting support from someone separate to their personal situation and who could therefore be more objective. Other respondents said they liked being signposted to resources for help with their issues, and that Shout was not just for crisis situations. 

One interviewee, who commissions Shout locally, found that a particular benefit of Shout actually comes from the fact that, while it has clinical supervision, it is not seen as “part of the system”. Some people do not want to enter the NHS system, but instead they want a confidential and anonymous service that enables them to get the support they need.  

2.2 Suitability of Shout

Shout was identified by one interviewee as being most helpful for two main groups of people. First, it supports people who find themselves in a crisis “that is not necessarily their normal or standard state”, who urgently need some advice and assistance that Shout’s protocol is well placed to provide. This can typically be a negative life event, such as a relationship failure or a bereavement:  

Second, it supports younger people who have coping problems, who need support and advice to get them through a particular period of their life. The approach taken by Shout Volunteers is similar to the counselling approach. The space and time to discuss a problem often enables people to come up with their own solution, which can have longer-term benefits for the individual as they navigate their own coping skills.

One interviewee described certain events that can exacerbate suicidal feelings, where Shout and other similar services can play an important role in mitigation. Events such as economic downturns, or the global uncertainty caused by the wars in Ukraine and Gaza, are recent examples. They emphasised the importance of briefing volunteers so that any additional guidance, resources or advice can be rapidly built into volunteer training or updated as appropriate when there are new unfolding crises that may affect many people. Overall, Shout was valued for its flexibility in dealing with whatever problems people were experiencing: 

Shout plays an important role in allowing private conversations. As a text message service, people can silently receive support in unsafe situations without fear of being overheard. This could include, for example, children experiencing abuse at home or people experiencing domestic violence. Shout also does not appear on people’s phone bills, therefore conversations can remain undetected. The Service User Voice Group also mentioned that it was easier for people to receive text support in a busy household than calls or therapy. 

A member of the Service User Voice Group, who is now also a Shout Volunteer, suggested that some texters would appreciate a conversation with an identified member of their peer group or community. One interviewee also suggested exploring the possibility for Shout to try to ​match texters to volunteers based on their cultural or ethnic group, to overcome some of the challenges they face in opening up about their mental health and reports of NHS staff not having appropriate knowledge or training in issues that certain communities (e.g. LGBTQ+) face.  

Most interviewees recognised how, for many people, a text-based service was a preferred way to access the support they need, compared to telephone, video or in-person services, with demand for it increasing. The Service User Voice Group described how a text-based platform allowed people time to process their emotions more easily, or to overcome some of the conversational challenges posed by, for example, neurodiversity,​ social anxiety disorder, deafness or hearing loss.

The anonymous and confidential nature of Shout, combined with a text platform that means people see no change in facial expression or tone of voice, enabled people to speak freely without experiencing feelings of shame or embarrassment. Having a record of the conversation, which can be referred back to at a later date including useful resources (e.g. Shout’s Little book of coping skills), was also considered extremely helpful at preventing a crisis recurring. In this sense, Shout was considered to be unique: 

2.4 National perspectives 

Overall, people who use Shout feel better for doing so. Based on data insights provided by MHI, since the service began in May 2018: 

• 83% of texters said that they found their conversation helpful 
• 66% of texters said they felt calmer  
• 59% of texters said they could work out their problems better. 

Interviewees spoke positively about the quality of the service offered by Shout. One interviewee emphasised the importance of reaching out to others when in crisis – but, if people are not properly trained and supported themselves to counsel someone, they can actually make things worse. Whereas, Shout Volunteers are appropriately trained and can escalate to clinicians if needed. Another interviewee commented that Shout involves active listening, so that people are not just given pre-prepared advice, but provide support based on what they are being told: 

Conducting emergency interventions of people who are felt to be at immediate risk of harm with the support of emergency services was considered by some interviewees as an extremely important part of the Shout offer. Shout’s ability to support people in such a wide range of circumstances was also considered a strength: 

Another area of impact highlighted by one interviewee was around its influence on national policy. The MHI team has representation, for example, on the National Suicide Prevention Strategy Advisory Group, and their data insights were valued and used by national policy makers. For example, the Suicide Prevention Strategy for England (2023-28) cites vital work conducted by Shout, such as its partnership with the Premier League to support the mental health of people in local communities, and its work to support people experiencing financial difficulties.  

2.5 Regional perspectives 

The data insights provided by MHI when Shout is commissioned locally were cited by interviewees from commissioning groups as important in demonstrating its impact and influencing future commissioning decisions. An example was the data insights received about the number of people who wanted to die by suicide and, during the conversation with Shout, the emergency services were called to support them and intervene. As of April 2024, there had been 33,000 interventions of this kind.  

Shout texters themselves have shared the impact that a conversation with a Shout Volunteer can have during these difficult moments. Quotes included in MHI’s Report on Shout’s role in UK suicide prevention stated: 

Given that there is no ongoing tracking of people, no information is available as to whether, for instance, that person eventually follows through with those intentions, or whether it leads to reduced pressure on services – but this is similar for other crisis services that Integrated Care Boards commission.  

Finally, those interviewed stated there would be value in volunteers being able to link to the full local directory of support services, so people could be directed appropriately, such as to the Citizens Advice Bureau or local food bank for example. MHI is exploring ways in which this may be achieved (see Next steps).  

​2.6 Demand for Shout 

Most interviewees praised Shout for its 24/7 availability, and how this addressed a notable gap in NHS and other voluntary sector mental health care provision. Analysis carried out by MHI in 2022 found that a Google search is the most common way for people to find out about Shout, with almost a third of texters hearing about Shout that way. Around half of these texters are searching for mental health helplines or support in general, rather than for Shout specifically. Around a fifth of these texters were specifically searching using suicide-related terms including, in a minority of cases, potentially harmful searches about suicide methods.  

The NHS website provides a list of free support services for people who need help with suicidal thoughts. It highlights Shout as the option for people who wish to text for help, alongside six other organisations they can contact through other means (summarised in Table 1 below). Many services are available 24/7, but some state that the length of a conversation may be shorter than usual during busy times later in the evening. Local support lines are also available in some parts of the UK. 

Figure 3 shows the number of conversations with people who texted Shout between May 2018 and December 2023. It shows a rapid rise in conversations between May 2018 and December 2021, before plateauing out from early 2022. At this point, MHI stopped proactively marketing Shout, due to the high levels of organic demand for the service and the financial constraints inherent in recruiting, training and supervising the additional volunteers that would be needed to take more conversations. 

Figure 4 shows a decrease in the number of first-time texters since the beginning of 2022, due to the aforementioned cessation of external marketing of the Shout number. The consistent number of returning texters over time demonstrates the value and usefulness of the service for people who had used the service previously. 

Figure 5 shows the distribution of conversations throughout the day over the same time period. At around the same time that conversations plateaued in early 2022, the distribution of conversations throughout the day also became more evenly spread. Shout took on paid crisis practitioners at around this time to provide additional, guaranteed support in taking nighttime conversations, when fewer volunteers are able to take shifts. This has allowed for consistent support at hours when more traditional services are unavailable. 

Interviewees and members of the Service User Voice Group commented on the importance of support being available in the evenings and weekends, due to people’s circumstances at home and employment commitments, and the periods when crises can often occur: 

An analysis of conversation times for returning texters further confirms this point. We looked at returning texters who had more than 5 conversations between May 2018 and December 2023. We classified texters by the time slot during which most of their conversations occurred. For example, if a texter had 3 conversations between 10 pm and 5 am, and 2 conversations between 5 am and 12 pm, they were assigned to the time slot “10 pm to 5 am”. We then looked at their distribution of conversations by time of day (Figure 6). We see that returning texters tend to favour a specific time of day/night for their conversations. This is true for all time slots, but particularly so for those who text during the night and early morning (between 6pm and 5 am). For this group, having a service that is available during the time when other services are not is particularly important.  

Many services that close overnight signpost to Shout’s 24/7 service at this time, leading to additional demand for the service. This can have an impact on how long people wait to access Shout. People tend to wait longer for the service during the night, when demand is at its peak.   

One way MHI aims to address this is through Shout’s triage system. Shout technology enables the triage of texters in the queue, so that people considered at highest risk (from the language they use when they reach out for support) receive priority attention. Priority can also be given where a specific keyword, as part of a campaign or commissioned activity, is used to access Shout by particularly at-risk populations.  

Currently, texters who are waiting to be paired with a volunteer receive a link to the Shout resources page, which signposts to tips, videos and coping strategies to help in different situations (e.g. self harm, panic attacks and bullying).  

The experience of waiting to be connected to a volunteer can vary depending on the texter’s unique circumstances. Some users find that just taking the first step of sending a message to Shout is helpful, whereas others find that extended waiting times and automated messages can actually exacerbate what they are going through.  

Accurately estimating waiting times is difficult, as these are influenced by time of day, day of week, triage of highest-risk texters, and external signposting and events outside of MHI’s control which can drive demand for the service. MHI will work with the Service User Voice Group to add information on the Shout website explaining these factors, so texters can better understand the drivers of waiting times and why they are variable. 

2.7 Barriers to access 

Several interviewees considered advantageous the fact that people do not need sophisticated technology to access support from Shout. It was noted, for example, that there are fewer barriers to people owning a phone that only ​​requires texting facility ​​(rather than requiring a “smart” phone and data allowance or ​broadband). ​

​​​Language was raised as a potential barrier by some interviewees. Based on data insights provided by MHI in 2022, texter survey responses showed that almost all (97%) texters communicate with English as their main language (compared with 91% of the population), suggesting that Shout may underrepresent people who do not communicate with English as their main language. This issue is not exclusive to Shout, as these groups may also struggle to access mental health services in general. 

​​​​One interviewee discussed the prevalence of traveller, migrant and asylum seeker communities in their region. This included a significant cohort of Ukrainian people and families, who may be suffering the mental health and wellbeing consequences of the war and also the separation anxiety and loneliness from being in a foreign country. People within these communities may also lack the language comprehension to find and access the services they need. ​​​​​People without mobile phones, people with inadequate mobile network coverage, people experiencing homelessness, and some older people, were considered by interviewees to be the groups facing the greatest barriers to using Shout. ​​​Ensuring adequate mental health support for these groups is a challenge for mental health services, more broadly, to consider collectively.  

3. Conclusions 

3.1 Why this matters 

It is becoming increasingly common for people to experience a problem with their mental health. A 2023 survey found that 1 in 5 children and young people aged 8 to 16 in England had a probable mental disorder, up from around 1 in 8 in 2017. For those aged 17-19, the rate was almost 1 in 4, up from 1 in 10, over the same time period. Analysis has also shown that the prevalence of depression increased due to the COVID-19 pandemic and the cost of living crisis. The last Adult Psychiatric Morbidity Survey (2014, due to re-run in 2024) found that 1 in 6 people aged 16 or over had experienced symptoms of a common mental health problem, such as depression or anxiety, in the previous week. 

The increase in demand for mental health support has led to​​ increased waits for people to receive the care and support they need. For example: 

• 1 in 10 people referred to NHS Talking Therapies wait more than 6 weeks to access the service. 
• 1 in 5 people with a mental health condition wait more than 12 weeks to start treatment, due to a lack of consultant psychiatrists. 
• Of the almost 950,000 children and young people referred to CAMHS in 2022/23, more than 270,000 were still waiting at the end of the year. 
• Waiting times for mental health care are rising rapidly and, if the trend continues, it will soon have the longest specialty waits in the NHS . 

The policy context shows an increased focus and commitment at a national level to improve access to care for people requiring support with their mental health. People in England and Wales can now press option 2 when they dial 111 to access mental health support from someone in a local crisis team. From April 2025, every region in England will be required to commission a crisis text messaging service. The Northern Ireland Mental Health Strategy 2021-31 identifies the increased access to digital mental health solutions as a key desired outcome (p.80).  

These developments, combined with the insights generated in this report, show how Shout plays a vital role in supporting people with their mental health, free of charge, any time they need it. Shout complements existing NHS and public services, and often meets a need for people who are not accessing any other form of support. In particular, Shout supports people experiencing a crisis in the evenings, when options other than attending A&E are rarely available. People who use Shout value it for its immediacy and its ability to help them cope in the short term when other services or support networks are not available. 

Despite some groups experiencing some potential barriers to using it, Shout’s text messaging platform provides unique advantages to support equity of access to mental health support. It enables entire sections of society to reach out for support, and engage with someone, who might not ordinarily be able to do so, or do so effectively. This includes, for example, younger people, people in unsafe situations, people who feel stigmatised for their identity or beliefs, people who are neurodivergent, Deaf or have hearing loss.  

Shout delivers an effective service, both in moments of severe distress and also as a preventative intervention. Most people who use it say they found their conversation helpful, they feel calmer, and they can work out their problem better, afterwards. Despite the challenges of demonstrating the impact of a confidential and anonymous service, the number of emergency interventions instigated by Shout where a texter is deemed to be at imminent risk of suicide, show the human, societal and economic benefit the service is delivering. This evidence is already being used by Integrated Care Systems to inform future commissioning decisions.  

Regional commissioners and national organisations should see Shout as a vital part of a whole system approach to improving mental health care, and explore ways to commission and fund Shout to support its expansion, given the important role it plays in addressing a current unmet need.  

3.2 Next steps 

MHI’s mission is to “use data-driven analysis, clinical expertise and technological innovation to develop and sustain pioneering digital products and services that meet underserved needs and that improve the mental health of the UK”. Learnings from the Shout service, Shout texters and the research around the service (such as this report) help MHI identify opportunities for improvement, either through Shout or through the development of new resources and services.  

For example, IGHI and MHI are looking to better understand the needs and preferences of 10 to 13-year-olds. To this effect, we are running a UK-wide survey through Place2Be schools in the Autumn of 2024 and focus groups to understand this group’s mental health status, coping strategies and support preferences. The project is being shaped by young people and will inform improvements of the Shout service to better cater to this group. The findings from this work will also be shared more broadly to support national-level service delivery.

MHI’s recent merger with The Mix will also allow us to strengthen our service offering for young people, gain further insights and ensure we can tailor our services further to meet young people’s needs. It will also ensure a comprehensive pathway of support is in place for those accessing MHI’s services, from early and targeted intervention, through to crisis support.

MHI is exploring ways to make Shout as accessible as possible to the broadest range of potential users. Ideas generated through this report include clearer information and signposting to people while they wait to speak to a volunteer, developing ways to match volunteers to texters from ethnic minorities and other underserved groups through new services, and exploring how ​​technology can make Shout a more inclusive service for digitally excluded people. The team are now considering all of these and how they could be worked into the Shout service.

MHI is also exploring how it can retain its value as a national service while tailoring the service it offers to local and regional systems. From 2025, NHSE has specified Integrated Care Boards should implement 24/7 crisis text messages service to support their 111 phone line provision. This should link with, and signpost to, local support networks to best meet the needs of the local population. In that regard, MHI’s pioneering partnership with ICBs through keyword services (see Boxes 5 and 6) can serve as a blueprint for others to deliver against this NHSE requirement. 

MHI is continuously looking at texter feedback to guide opportunities for improvement, such as the reduction in waiting times. To do this, MHI are consistently seeking funding that will allow it to ensure it continues to have sufficient capacity to meet demand. This may include the potential expansion of international and paid volunteer roles, offering enhanced training and support to volunteers, as well as consideration of how it may match volunteers to texters with specific knowledge or lived experience (e.g., LGBTQ+, under-represented, underserved, ​​cultural, ethnic or minoritised groups), while still protecting their anonymity.  

As Shout and other MHI services evolve, MHI intends to continue to collaborate and partner with national bodies, including multiple Government departments, to ensure insights from their unique datasets will continue to inform national policy-making and service design (See Box 4). MHI is also actively seeking further opportunities to partner with national bodies and embed their insights at the heart of national decision-making.