Suicide Prevention Training: Policies for Health Care Professionals Across the United States as of October 2017 Janessa M. Graves, PhD, MPH, Jessica L. Mackelprang, PhD, Sara E. Van Natta, RN, and Carrie Holliday, PhD, MN, ARNP Objectives. To identify and compare state policies for suicide prevention training among health care professionals across the United States and benchmark state plan updates against national recommendations set by the surgeon general and the National Action Alliance for Suicide Prevention in 2012. Methods. We searched state legislation databases to identify policies, which we de- scribed and characterized by date of adoption, target audience, and duration and fre- quency of the training. We used descriptive statistics to summarize state-by-state variation in suicide education policies. Results. In the United States, as of October 9, 2017, 10 (20%) states had passed legislation mandating health care professionals complete suicide prevention training, and 7 (14%) had policies encouraging training. The content and scope of policies varied substantially. Most states (n = 43) had a state suicide prevention plan that had been revised since 2012, but 7 lacked an updated plan. Conclusions. Considerable variation in suicide prevention training for health care pro- fessionals exists across the United States. There is a need for consistent polices in suicide prevention training across the nation to better equip health care providers to address the needs of patients who may be at risk for suicide. (Am J Public Health. 2018;108:760– 768. doi:10.2105/AJPH.2018.304373) See also Caine and Cross, p. 717. The number of suicides annually in theUnited States exceeds that of traffic crashes or homicide, rendering it the 10th leading cause of death.1 In 2013, 42 826 in- dividuals died by suicide in theUnited States.1 The mortality rate for suicide has increased 24% since 1999 and is currently 13 per 100 000 people,which equates to 115 suicides every day.2 Because of its high incidence and potential for prevention, determining how to most effectively prevent suicide is a public health imperative.3 Health care professionals regularly en- counter patients at risk for suicide. In an Australian study, 75% of individuals who died by suicide had seen a health care professional within 3 months preceding their death.4 This suggests health care professionals may play a critical role in identifying at-risk patients and in preventing suicide. However, health care professionals are often not equipped with the training necessary to effectively identify and manage patients at risk for suicide.3,5,6 Even among mental health providers, training in suicide assessment and intervention is not ubiquitous, despite calls for increased training since the late 1980s.7–9 Patients at risk for suicide may, therefore, be inadequately identified and not receive appropriate treatment. In 2001, the US surgeon general released National Strategy for .

1. Suicide Prevention Training: Policies for Health
Care Professionals Across the United States
as of October 2017
Janessa M. Graves, PhD, MPH, Jessica L. Mackelprang, PhD,
Sara E. Van Natta, RN, and Carrie Holliday, PhD, MN, ARNP
Objectives. To identify and compare state policies for suicide
prevention training
among health care professionals across the United States and
benchmark state plan
updates against national recommendations set by the surgeon
general and the National
Action Alliance for Suicide Prevention in 2012.
Methods. We searched state legislation databases to identify
policies, which we de-
scribed and characterized by date of adoption, target audience,
and duration and fre-
quency of the training. We used descriptive statistics to
summarize state-by-state
variation in suicide education policies.
Results. In the United States, as of October 9, 2017, 10 (20%)
states had passed

2. legislation mandating health care professionals complete suicide
prevention training,
and 7 (14%) had policies encouraging training. The content and
scope of policies varied
substantially. Most states (n = 43) had a state suicide prevention
plan that had been
revised since 2012, but 7 lacked an updated plan.
Conclusions. Considerable variation in suicide prevention
training for health care pro-
fessionals exists across the United States. There is a need for
consistent polices in suicide
prevention training across the nation to better equip health care
providers to address
the needs of patients who may be at risk for suicide. (Am J
Public Health. 2018;108:760–
768. doi:10.2105/AJPH.2018.304373)
See also Caine and Cross, p. 717.
The number of suicides annually in theUnited States exceeds
that of traffic
crashes or homicide, rendering it the 10th
leading cause of death.1 In 2013, 42 826 in-
dividuals died by suicide in theUnited States.1
The mortality rate for suicide has increased
24% since 1999 and is currently 13 per
100 000 people,which equates to 115 suicides

3. every day.2 Because of its high incidence and
potential for prevention, determining how to
most effectively prevent suicide is a public
health imperative.3
Health care professionals regularly en-
counter patients at risk for suicide. In an
Australian study, 75% of individuals who died
by suicide had seen a health care professional
within 3 months preceding their death.4 This
suggests health care professionals may play
a critical role in identifying at-risk patients and
in preventing suicide. However, health care
professionals are often not equipped with the
training necessary to effectively identify and
manage patients at risk for suicide.3,5,6 Even
among mental health providers, training in
suicide assessment and intervention is not
ubiquitous, despite calls for increased training
since the late 1980s.7–9 Patients at risk for
suicide may, therefore, be inadequately
identified and not receive appropriate
treatment.
In 2001, the US surgeon general released
National Strategy for Suicide Prevention, a
groundbreaking report that outlined a series
of goals to galvanize the nation’s suicide
prevention efforts, which included urging
states to develop comprehensive suicide
prevention plans.10 The subsequent report,
issued in 2012 by the surgeon general and the
National Action Alliance for Suicide Pre-
vention, noted variation in state plans (in-

4. cluding the need to address suicide across the
lifespan), underscored the importance of in-
cluding multiple sectors in prevention plans,
and emphasized that education on suicide
prevention should be mandated by cre-
dentialing and accreditation bodies relevant to
health professions.3 Specifically, the report
stated that undergraduate and graduate pro-
grams for health professionals should “ensure
that graduates achieve the relevant core
competencies in suicide prevention appro-
priate for their respective discipline.”(p47)
That report further established benchmark
standards for suicide prevention education by
advising that curricula be evidence based and
by describing ways states may promote the
adoption of suicide prevention training by
legislating minimum standards of training.
The 2012 National Strategy for Suicide Pre-
vention was not alone in encouraging suicide
awareness and prevention education for
health care professionals. The World Health
Organization asserted that health care pro-
fessionals (e.g., physicians, nurses, psychologists,
social workers, emergency medical staff) are
among the key stakeholders responsible for
preventing suicide. Indeed, suicide prevention
experts have reiterated that health care pro-
fessionals are in an optimal position to contribute
to suicide prevention, if properly trained.9
ABOUT THE AUTHORS
Janessa M. Graves, Carrie Holliday, and Sara Van Natta are
with the College of Nursing, Washington State University,

5. Spokane. Jessica L. Mackelprang is with the Department of
Psychological Sciences, Swinburne University of Technology,
Melbourne, Australia. Sara E. Van Natta is also with Seattle
Children’s Hospital, Seattle, WA.
Correspondence should be sent to Janessa M.Graves,Washington
State University, College of Nursing, POBox 1495, Spokane,
WA 99210 (e-mail: [email protected]). Reprints can be ordered
at http://www.ajph.org by clicking the “Reprints” link.
This article was accepted February 8, 2018.
doi: 10.2105/AJPH.2018.304373
760 Public Health Ethics Peer Reviewed Graves et al. AJPH
June 2018, Vol 108, No. 6
AJPH LAW & ETHICS
mailto:[email protected]
http://www.ajph.org
In response to these calls to action, some
states have implemented policies that en-
courage or require suicide prevention training
for “qualified health care professionals,”
a broad descriptor defined differently be-
tween states. With the passing of the Matt
Adler Suicide Assessment, Treatment, and
Management Act (“Adler Act”; House Bill
2366), Washington became the first state to
mandate suicide-related training in clinical
practice. The Adler Act was passed in 2012
and requires the following “qualified health
care professionals” to complete suicide pre-
vention and assessment training: advisers,

6. counselors, chemical dependency pro-
fessionals, marriage and family therapists,
mental health counselors, occupational
therapy practitioners, psychologists, and social
workers.
In 2014, the Adler Act was amended to
include additional disciplines: chiropractors,
dentists, dental hygienists, naturopaths,
licensed practical nurses, registered nurses,
advanced registered nurse practitioners,
physicians and surgeons (allopathic and os-
teopathic), physician assistants (allopathic and
osteopathic), physical therapists, and physical
therapist assistants (House Bill 2315, 2014).
Effective July 23, 2017, the listedWashington
health care professionals were mandated to
complete at least 6 hours of continuing ed-
ucation on suicide assessment, treatment, and
management. Trainings must be established
in consultation with experts and must “in-
clude content specific to veterans and the
assessment of issues related to imminent harm
via lethal means or self-injurious behaviors.”
For select professions identified by disci-
plining authorities (e.g., pharmacists, den-
tists), training may be reduced to 3 hours.
After the passage of the Adler Act, several
states developed similar legislation; however,
the status of and variation in state-based
policies mandating suicide prevention train-
ing has not been reported. We documented
the status of state suicide prevention plans and
examined policies mandating suicide pre-
vention training for qualified health care

7. professionals across the United States, in-
cluding variation in the target audience,
duration of mandated training, and frequency
of training. Determining how laws vary across
the nation may aid states in developing or
refining legislation related to suicide pre-
vention education, potentially promoting
greater consistency of training between states.
This may, in turn, lead to improvements in
suicide prevention, assessment, management,
and treatment on a national scale.
METHODS
We employed 2 approaches to identify
state policies related to suicide prevention
education for health care providers. We
queried online legislation databases for each
state legislative branch (e.g., Washington
State: www.apps.gov.wa/billinfo). Because
the search capacity of some state databases is
limited, we also searched for legislative in-
formation from each state’s House and Senate
using 2 legislation tracking services that record
the history, updates, and ongoing processes of
state bills (i.e., Open States and LegiScan) to
ensure that the data were comprehensive.We
used the following search terms: “suicide,”
“suicide prevention training,” “health care
professional,” and “health care professional.”
We conducted an initial search on January 28,
2017. We repeated the search on October 9,
2017. We re-reviewed all policies to ensure
bill data were up to date.

8. We employed 2 methods to ensure the
validity of policy data. First, we examined
historical notes for each law, such as legislative
bills and initiatives (available on state data-
bases) for policy details, information, focus,
and specific action dates (e.g., date of adop-
tion). We coded amendments to bills as data
for that piece of legislation, thereby over-
riding the original version of the bill. Second,
we located supplemental documentation
using resources archived online by the Suicide
Prevention Resource Center.11 We first
identified states’ most recent suicide pre-
vention plans through the Suicide Prevention
Resource Center archive and then confirmed
them individually via state government Web
sites. If we could not locate state plans, we
obtained confirmation via online search en-
gines or communication with state contacts
listed on the Suicide Prevention Resource
Center Web site.
Definitions
We defined suicide prevention training as
any training intended to inform qualified
health care professionals about suicide
prevention, assessment, management, or
treatment. We separated qualified health care
professionals into 2 categories: (1) mental
health and behavioral health care pro-
fessionals, and (2) general health care pro-
fessionals. The definition of a health care
professional varies between states. For ex-
ample, the bill mandating suicide prevention

9. training for health care professionals in Utah
(House Bill 209, signed 2015) targets be-
havioral health care professionals, defined as
recreational therapists, social workers, mar-
riage and family therapists, clinical mental
health counselors, and substance use disorder
counselors. In Washington State, the defi-
nition is broader; it includes registered nurses
and physicians, among others.
For the purpose of this study,mental health
and behavioral health care professionals were
professionals who provide clinical care with
the objective of improving mental health or
conducting mental health research. These
included psychiatrists, psychologists, social
workers, counselors (including rehabilitation
counselors and licensed behavioral coun-
selors), behavior analysts, psychiatric and
mental health nurse practitioners, and occu-
pational therapists. General health care
professionals included physicians (not psy-
chiatrists), nurse practitioners (not explicitly
defined as psychiatric or mental health nurse
practitioners), certified nurse specialists,
physician assistants, certified nurse midwives,
certified registered nurse anesthetists, physical
therapists, medical assistants, licensed practical
nurses, and registered nurses.
Policy Variables
We coded each state policy in relation to
the following characteristics: law or bill
name and number, date of adoption, target
audience, training duration, and training

10. frequency. We defined target audience as
the groups of qualified health care pro-
fessionals mandated to receive training. Date
of adoption was the day, month, and year
when the policy was signed or approved by
the governor after being passed by the leg-
islature or when the policy was ratified,
whichever occurred first. Duration was the
length of the training (in hours) mandated by
the legislation. Duration included the initial
training duration and subsequent required
training, if specified. Frequency of training
AJPH LAW & ETHICS
June 2018, Vol 108, No. 6 AJPH Graves et al. Peer Reviewed
Public Health Ethics 761
http://www.apps.gov.wa/billinfo
was how often the training must be
completed.
We coded each state suicide prevention
plan dichotomously as “updated” (amended
or issued in 2012 or after) or “not updated”
(issued before 2012 and thereby lacking
amendment in response to the 2012 National
Strategy for Suicide Prevention).3
Data Analysis
We entered data into Microsoft Excel
(Microsoft Corp., Redmond, WA) to sum-
marize variables.We used descriptive statistics

11. (e.g., frequency distributions, counts) to de-
scribe variation in legislative characteristics
across the United States, including existence
of a policy, target audience, duration and
frequency of training, and updated versus not
updated.
RESULTS
As ofOctober 9, 2017, all states had a state
suicide prevention plan. Forty-three (86%)
states had a state suicide prevention plan that
had been issued or revised in 2012 or later
(Figure 1; Figure A, available as a supple-
ment to the online version of this article at
http://www.ajph.org), whereas 7 (14%)
states did not (Table 1). Most state suicide
prevention plans were written for the
general population, but a few (e.g., Oregon,
Pennsylvania) had plans for suicide pre-
vention among youths or older adults
specifically.
Sixteen (32%) states had a policy related to
suicide prevention training for health care
professionals generally or for mental or be-
havioral health care professionals specifically,
10 of which had 1 ormore policies mandating
training for qualified health care professionals
(Table 2). In most states, the target audience
was mental or behavioral health care pro-
fessionals (Table 2). In Indiana, the target
audience was emergency medical services
providers exclusively. In Washington,
Nevada, and West Virginia, general health

12. care professionals (e.g., nurses, physicians)
were also required to complete training. The
duration and frequency of training mandated
in those 10 states varied from 1 or more hours
on license renewal to 6 hours every 6 years
(Table 2). The training requirements for
mental and behavioral health care pro-
fessionals in Washington State were more
stringent than were the requirements for
general health care providers (i.e., 6 hours
every 6 years vs 6 hours 1 time).
Seven states had enacted policies that
encourage qualified health care professionals
to complete suicide prevention training
(Tables 1 and 2; Figure B, available as a sup-
plement to the online version of this article at
http://www.ajph.org). For example, Mon-
tana required the state suicide prevention
program to include training related to suicide
assessment for health care professionals.
Similarly, Colorado encouraged the Suicide
Prevention Commission, among other enti-
ties, to host training opportunities for health
care providers (Table 2). Training was not
mandated in any of those states, however,
except Indiana, where training was both
mandated and encouraged.
In addition to the 16 states with legislation
mandating or encouraging training for health
care providers, 5 had legislation in progress at
the time of this writing that, if passed, would
affect training on suicide prevention for
health care professionals (Table 1; Figure B).

13. Of the 2 bills under consideration inMissouri,
1 would mandate training for mental or be-
havioral health care providers and the other
would require training for pharmacists. In
New Jersey, the proposed policies related
specifically to general health care providers
who care for pediatric patients. Texas had 2
bills in progress, 1 targeting general health
care professionals and 1 focusing onmental or
behavioral health care professionals. The bill
under consideration in Virginia would re-
quire training for general health care pro-
fessionals. Lastly, North Carolina had a bill in
progress related to state suicide prevention
plan activities, including providing, but not
requiring, training for health care providers.
Connecticut, Maine, and Minnesota had
bills that failed to pass the Senate or House in
recent years and did not have policies under
consideration at the time of this study.
2% 2% 2% 2% 2%
4%
12%
10%
8%
18% 18%
20%
0

14. 5
10
15
20
25
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20

15. 09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
Pe
rc
en
ta
ge
o
f

16. St
at
es
Year
Updated prior to 2012
Updated in 2012 or later
(n = 1)(n = 1) (n = 1) (n = 1) (n = 1)
(n = 2)
(n = 6)
(n = 5)
(n = 4)
(n = 9) (n = 9)
(n = 10)
FIGURE 1—Publication Years for US State Suicide Prevention
Plans Relative toRelease of the 2012National Strategy for
Suicide Prevention as
of October 9, 2017
AJPH LAW & ETHICS
762 Public Health Ethics Peer Reviewed Graves et al. AJPH
June 2018, Vol 108, No. 6
http://www.ajph.org
http://www.ajph.org

17. TABLE 1—Status of State Suicide Prevention Plans in the
United States on October 9, 2017
Suicide Prevention Plan Status and Scope of Suicide Prevention
Training Policy
State
Not Revised Since
2012
Revised Since
2012
Adopted, Requires
Training
Adopted, Encourages
Training
In Progress, Requires
Training
In Progress, Encourages
Training
No
Policy
Alabama X X
Alaska X X
Arizona X X

18. Arkansas X X
California X X
Colorado X X
Connecticut X X
Delaware X X
Florida X X
Georgia X X
Hawaii X X
Idaho X X
Illinois X X
Indiana X X X
Iowa X X
Kansas X X
Kentucky X X
Louisiana X X
Maine X X
Maryland X X
Massachusetts X X

19. Michigan X X
Minnesota X X
Mississippi X X
Missouri X X
Montana X X
Nebraska X X
Nevada X X X
New
Hampshire
X X
New Jersey X X
New Mexico X X
New York X X
North
Carolina
X X
North Dakota X X
Ohio X X

20. Oklahoma X X
Oregon X X
Pennsylvania X X
Continued
AJPH LAW & ETHICS
June 2018, Vol 108, No. 6 AJPH Graves et al. Peer Reviewed
Public Health Ethics 763
Among the 24 states that had made
progress in expanding suicide prevention
training by either mandating, encouraging, or
introducing bills (i.e., under consideration or
failed) that would strengthen training re-
quirements for health care professionals, 5
(i.e., California, Illinois, Louisiana, Michigan,
and West Virginia) had not revised their state
suicide prevention plan since 2012.
DISCUSSION
The 2012 National Strategy for Suicide Pre-
vention outlined priority areas and strategic
directions for suicide prevention on a national
scale, including the importance of compre-
hensive state-based suicide prevention plans
and suicide prevention training for personnel
in health professions. We documented the
status of state suicide prevention plans across

21. the United States and examined policies
mandating suicide prevention training for
health care professionals. According to this
study, 5 years after the release of the 2012
report, 14% (n= 7) of states had yet to revise
their plans in accordance with the updated
national strategy. However, there has been
a surge in the number of plans updated in
recent years (Figure 1), which may indicate
collective momentum toward preventing
suicide across the nation. Despite the explicit
recommendation that education on suicide
prevention be incorporated into the training
of health care professionals, however, few
states require such education.
It is critical that each state maintain
a comprehensive suicide prevention plan that
tailors national recommendations to the
unique needs of their population. State plans
are essential for identifying and engaging
relevant stakeholders, including credentialing
bodies that oversee the practice of health care
professionals, and to ensuring implementa-
tion of actions toward attaining suicide pre-
vention goals. Of the 10 states with a policy
mandating that health care professionals
complete training specific to suicide pre-
vention, most targeted mental and behavioral
health care professionals. Only 3 (i.e.,
Nevada, Washington, West Virginia) have
broadened the target audience to include
some general health care professionals, and 1
(i.e., Indiana) included only professionals who
deliver emergencymedical services.We hope

22. more states will heed the urgings of the
surgeon general, the National Alliance for
Suicide Prevention, and suicide prevention
experts to ensure that the spectrum of health
care providers are sufficiently trained.3,12
Health care professionals are uniquely
situated to identify individuals who may be at
risk for suicide and to provide or facilitate
access to treatment. However, this is possible
only if health care professionals are equipped
with the necessary knowledge and skills to
intervene in an ethical and evidence-based
manner. Schmitz et al. argue that the “lack
of training required of mental health pro-
fessionals regarding suicide has been an
egregious, enduring oversight by the mental
health disciplines.”9(p297) The same can be
argued for other health care professionals,
who, despite limited training, are often the
primary communicators with patients at risk
for suicide. For example, nurses are frontline
providers who interact with patients at risk for
suicide; however, such patients may not be
identified because of the lack of suicide
prevention training in nursing curricula.5
General health care professionals are also
more likely than are mental health providers
to be the last point of contact in the health care
system for a suicide decedent.4,13,14 Because
of the variability in state plans, it should come
as no surprise that in a recent study, Silva et al.
found differences in suicide knowledge and
confidence in working with suicidal people

23. among a large sample of behavioral health
professionals from several states.15 States with
the highest levels of knowledge had enacted
suicide prevention initiatives several years
before the study, which the authors posited
may have explained the differences.
The toll of suicide across the United States
is great in terms of emotional suffering,
TABLE 1—Continued
Suicide Prevention Plan Status and Scope of Suicide Prevention
Training Policy
State
Not Revised Since
2012
Revised Since
2012
Adopted, Requires
Training
Adopted, Encourages
Training
In Progress, Requires
Training
In Progress, Encourages
Training
No

24. Policy
Rhode Island X X
South
Carolina
X X
South Dakota X X
Tennessee X X
Texas X X
Utah X X
Vermont X X
Virginia X X
Washington X X
West Virginia X X
Wisconsin X X
Wyoming X X
AJPH LAW & ETHICS
764 Public Health Ethics Peer Reviewed Graves et al. AJPH
June 2018, Vol 108, No. 6

25. TABLE 2—Target Audience, Duration, Frequency, Date of
Adoption, Bill and State Policies Related to Suicide Prevention
Training for Health
Care Professionals in the United States on October 9, 2017
State Law or Bill
Date of
Adoption Target Audience or Content/Explanation Minimum
Duration and Frequency
States with laws that require training
California Assembly Bill 89 09/01/2017 Psychologists 6 h at the
point of licensure, renewal, or
reinstatement
Indiana House Bill 1430a 04/28/2017 Emergency medical
services providers Not specified
Kentucky KRS 210:366
(House Bill 92)b
03/20/2015 Social workers, marriage and family therapists,
professional
counselors, pastoral counselors, and psychologists; alcohol and
drug
counselors, occupational therapists, peer support specialists
6 h every 6 y (3-h training may be approved for
content appropriate for profession or if content is

26. outside the professional’s scope of practice)
Nevada Assembly Bill 105c 05/26/2017 Physicians, physician
assistants, advanced practice registered nurses,
osteopathic physicians, psychologists, certified autism behavior
interventionists
2 h within 2 y of initial licensure; 2 h every 4 y
thereafter
Detoxification technicians, alcohol, drug, and gambling
counselors 1 h of instruction for each year of certification
Marriage and family therapists, clinical professional counselors
2 h every 2 y to renew license
Assembly Bill 387 05/08/2017 Social workers 2 h every 2 y to
renew license
Senate Bill 286 06/14/2017 Licensed behavior analysts, licensed
assistant behavior analysts 2 h as condition of license renewal
New Hampshire Senate Bill 33 05/07/2015 Pastoral
psychotherapists, clinical social workers, clinicalmental health
counselors, marriage and family therapists
3 h every 2 y to renew license
Pennsylvania House Bill 64 07/08/2016 Psychologists, social
workers, marriage and family therapists,
professional counselors
1 h as a condition to renew license

27. Tennessee Senate Bill 489;
House Bill 948
05/19/2017 Social workers, marriage and family therapists,
professional
counselors, pastoral counselors, alcohol and drug abuse
counselors,
psychologists, occupational therapists, other direct staff
working in
the field of mental health and substance abuse
2 h every 2 y
Utah House Bill 209 03/23/2015 Therapeutic recreation
technicians, recreation specialists, recreational
therapists, clinical social workers, certified social workers,
social
service workers, marriage and family therapists, clinical mental
health counselors, substance use disorder counselors
2 h as condition of licensure and license renewal
Washington RCW 43.70.442
(House Bill 1424)d
05/10/2017 Chiropractors, dentists, dental hygienists,
naturopaths, licensed

28. practical nurses, registered nurses, advanced registered nurse
practitioners, osteopathic physicians, osteopathic physician
assistants, physical therapists, physical therapist assistants,
physicians, physician assistants (does not include certified
registered
nurse anesthetists, osteopathic physicians and surgeons who
hold
a postgraduate license in osteopathic medicine or surgery, or
physicians who are residents holding a limited license)
6 h 1 time (3-h training may be approved if content
is outside the professional’s scope of practice)
Advisers, counselors, chemical dependency professionals,
marriage and
family therapists, mental health counselors, occupational
therapy
practitioners, psychologists, advanced social workers,
independent
clinical social workers, social worker associates
6 h every 6 y (3-h training may be approved if
content is outside the professional’s scope of
practice)

29. West Virginia House Bill 2804e 04/26/2017 Registered
professional nurses (registered nurses and licenses practical
nurses), advanced nurse practitioners, psychologists, social
workers,
professional counselors
2 h for each renewal/reporting period for
continuing education requirements
States with laws that encourage training
Colorado Senate Bill 147 05/04/2016 Suicide prevention
commission and other entities are strongly
encouraged to develop and implement professional development
resources and training opportunities for health systems,
including
mental and behavioral health systems, primary care providers,
physician and mental health clinics in educational institutions,
and
community mental health centers
NA
Continued
AJPH LAW & ETHICS

30. June 2018, Vol 108, No. 6 AJPH Graves et al. Peer Reviewed
Public Health Ethics 765
medical costs, and lost productivity. That
burden is carried by individuals who expe-
rience suicidal ideation and survive attempts,
the loved ones of those individuals and those
bereaved by suicide, and the health care
professionals who care for those individuals
and families. Death of a patient by suicide has
serious personal and professional ramifications
for health care providers.16–19 Although
health care professionals are routinely tasked
with the responsibility of providing care to
patients who may be at risk for suicide, ed-
ucation on the topic is not a compulsory
aspect of most educational programs. Despite
calls to action over 3 decades from academics
TABLE 2—Continued
State Law or Bill
Date of
Adoption Target Audience or Content/Explanation Minimum
Duration and Frequency
Hawaii CCR 157 (House Bill
55, HD1 SD2 CD1)
05/03/2007 States that the department of health may establish
and operate

31. a statewide suicide early intervention and prevention program to
carry out suicide prevention training programs for health care
providers
NA
Illinois 410 ILCS 53/30
(House Bill 1643)
08/13/2007 Encourages the director of public health to ensure
that pilot suicide
prevention plans (outlined in the legislation) include training
for
health providers and physicians
NA
Indiana House Bill 1430a 04/27/2017 The Division of Mental
Health and Addiction to develop and provide an
evidence-based training program for health care providers,
including
mental health and behavioral health providers
NA
Louisiana RS 37:24–27
(Senate Bill 539)

32. 06/09/2014 Requires the Louisiana Department of Health and
Hospitals to offer
the following professionals certified, licensed, or registered in
Louisiana access to a list of training programs in suicide
assessment,
intervention, treatment, and management through posting links
to
such trainings on the department’s official Web site: mental
health
counselors, social workers, psychiatrists, physicians, surgeons,
midwives, psychologists, medical psychologists, registered
nurses or
advance practice registered nurses, physician assistants,
addiction
counselors
NA
Michigan . . .f Public acts related to appropriations for
community health that include
statements regarding “initiatives that train health care
practitioners
and faculty in managing pain, providing palliative care and
suicide

33. prevention”
NA
Montana MCA 53–21-1101
(Senate Bill 478)
05/08/2007 Requires state suicide prevention officer to direct
statewide suicide
prevention program with evidence-based activities, including
training for medical professionals, social service providers, and
other
groups on recognizing the early warning signs of suicidality,
depression, and other mental illnesses
NA
Note. NA =not applicable. Data are fromsearchesof individual
state legislativeWeb sites,Open States, and LegiScan andare
accurate asofOctober 9, 2017. Bills
passed subsequent to this date are not included.
aIndiana House Bill 1430 includes text requiring emergency
medical services providers to complete suicide prevention
training as well as text relating to the
provision of a suicide prevention training program for health
care providers.
bKentucky State legislation was originally adopted into law as
Senate Bill 72 (2013) and later expanded to include alcohol and
drug support peer specialists
in 2015 (House Bill 92).
cNevada State legislationwasoriginally adopted into

34. lawasAssembly Bill 93 (2015) and later amendedwithAssembly
Bill 105 (2017), SenateBill 286 (2017), and
Assembly Bill 387 (2017) to revise training requirements.
dWashington State legislation was originally adopted into law
as House Bill 2366 (2012) and was amended in 2013 (House
Bill 1376), 2014 (House Bill
2315), 2015 (House Bill 1424), 2016 (House Bill 2793), and
2017 (House Bill 1424). The information here refers to the most
recently adopted
amendment.
eWest Virginia House Bill 2804 specifies that trainingmust
pertain tomental health conditions common to veterans and
family members of veterans, including
training on inquiring aboutwhether the patients are veterans or
familymembers of veterans and screening for conditions such as
posttraumatic stress disorder,
risk of suicide, depression, and grief and prevention of suicide.
fSeveral Michigan State Public Acts for appropriations were
identified (e.g., 2002 Public Act 519) that include the following
statement: “The department shall
promote activities that preserve the dignity and rights of
terminally ill and chronically ill individuals. Priority shall be
given to programs, such as hospice, that
focus on individual dignity and quality of care provided persons
with terminal illness and programs serving persons with chronic
illnesses that reduce the rate
of suicide through the advancement of the knowledge and use of
improved, appropriate pain management for these persons; and
initiatives that train health
care practitioners and faculty in managing pain, providing
palliative care and suicide prevention.” However, no bills
related to suicide prevention education for
health care providers (beyond the appropriations) were
identified.
AJPH LAW & ETHICS

35. 766 Public Health Ethics Peer Reviewed Graves et al. AJPH
June 2018, Vol 108, No. 6
and policymakers alike, relatively modest
increases in suicide prevention training
have been observed among health-related
training programs. As a result, despite
frequently encountering suicidal patients,
many mental, behavioral, and general
health care professionals continue to
report a paucity of training or limited
confidence in working with at-risk
patients.20,21
Even among health care professionals who
endorse a good level of knowledge and
confidence in suicide assessment, the majority
are keen to receive further training.22 Pre-
vious research suggests that lack of training is
a common reason qualified health care pro-
fessionals have a negative attitude toward
working with patients at risk for suicide,23
whichmay affect the quality of care provided.
This gap in training calls into question
whether health care professionals are in-
advertently practicing beyond the boundaries
of their competence.9 Studies have shown
that suicide prevention training strengthens
skills and knowledge and improves attitudes
among health care professionals.24–28 Perhaps
mandatory trainingwill be necessary to ensure
that health care professionals are prepared

36. with the skills necessary to identify and sup-
port at-risk patients, particularly if future
research identifies a relationship between
compulsory training and improved patient
outcomes.
Although legislation may be an effective
way to ensure that suicide prevention training
is disseminated universally among health care
professionals, additional approaches to tack-
ling deficits in knowledge and skills exist.
Accrediting bodies (e.g., American Psycho-
logical Association, Liaison Committee on
Medical Education) have a responsibility to
ensure that graduates are prepared to identify
patients at risk for suicide and to respond
appropriately. These bodies could revise
standards to introduce core competencies
related to suicide assessment, as proposed by
Schmitz et al.9 There are also evidence-based
gatekeeper trainings produced by professional
organizations, such as the Recognizing and
Responding to Suicide Risk (http://www.
suicidology.org/training-accreditation/rrsr),
Applied Suicide Intervention Skills Training
(https://www.livingworks.net/programs/
asist), and Question, Persuade, and Refer
training (https://www.qprinstitute.com),
all of which provide individual- or
organization-level training.
Limitations and Directions For
Future Research
The most important measure of the ef-

37. fectiveness of policies mandating suicide
prevention training for health care pro-
fessionals is whether suicide-related outcomes
(e.g., rate of completed suicides or hospital-
izations for suicide attempts) change. How-
ever, limited time has elapsed since the
enactment of state policies to demonstrate
whether a relationship exists between man-
datory training and suicide rates; such data are
not yet available. Nonetheless, it is promising
that health care professionals in states with
established suicide prevention initiatives have
been shown to evidence higher knowledge
and confidence in working with suicidal
people.15 Longitudinal analyses to evaluate
whether mandatory suicide prevention
training for qualified health care professionals
affects state suicide rates may be a viable
method. Similar methods were used inRussia
to investigate the impact of a national alcohol
policy on suicide rates.29
Future research is needed to establish best
practice training guidelines for health care
professionals. Discussion of access to lethal
means should be included, including access to
firearms, which are used in 50% of suicides in
the United States (this rate is 8 times greater
than that of other high-income nations).30
Differences between states should be con-
sidered, as some risk factors (e.g., rates of
firearm ownership) are associated with par-
ticularly high levels of risk.31 Moreover, it
behooves states to establish data collection
plans at the inception of policy changes; this

38. would enable the evaluation of mandated
training, including provider knowledge
and skills before and after training, fidelity
to best practice training approaches, and
suicide-related patient outcomes.
Currently, the duration and frequency of
mandated training vary widely. Some state
policies require that a specific number of
hours be completed at a particular cadence
(e.g., every 2 years) as a component of con-
tinuing education (i.e., postlicensure),
whereas others mandate that training be
completed as a condition of obtaining li-
censure. This is problematic, particularly at
the doctoral level, because physicians- and
psychologists-in-training often relocate to
different states to complete their residency or
predoctoral internship, respectively. If edu-
cation on suicide prevention is mandated for
health care professionals only during con-
tinuing education, wemust assume that many
professionals enter the workforce and take on
the responsibility of managing at-risk patients
without sufficiently robust skills to do so.
The legislative landscape is perpetually
changing, and this topic is gaining momen-
tum as a governmental priority. Thus, bills
under consideration at the time of this
writing, for example, may or may not pass.
Ongoing monitoring of legislative changes
related to suicide prevention education re-
quirements for health care professionals will
be necessary. Amendments result in updates

39. to the date of adoption and, oftentimes,
changes in bill numbers. This could com-
plicate replication, as policy details—the data
—may change with amendments. Because
each state defines qualified health pro-
fessionals differently, disparate terminology
should be considered when evaluating poli-
cies on a national level. Lastly, the scope of this
studywas limited to universal polices focusing
on training for health care professionals, and
search results do not include professionals in
specialized settings (e.g., schools, correctional
facilities).
Conclusions
Suicide is a serious and preventable public
health concern that has substantial and en-
during impacts on individuals, families, and
communities. We have provided a snapshot
of current policies across the nation and dis-
cussed means by which knowledge and skills
gaps may be addressed. By comparing state
policies—specifically the date of adoption or
introduction, target audience, duration, and
frequency—our findings illustrate the gross
variability in policies between states and
underscore the amount of work yet to be
done to address the priority areas outlined in
the 2012 National Strategy for Suicide Pre-
vention, including requiring suicide preven-
tion education for health care professionals.3
Better equipping health care professionals
to assess and provide care to patients at risk
for suicide may contribute to a meaningful

40. decline in the rate of suicide across the nation,
AJPH LAW & ETHICS
June 2018, Vol 108, No. 6 AJPH Graves et al. Peer Reviewed
Public Health Ethics 767
http://www.suicidology.org/training-accreditation/rrsr
http://www.suicidology.org/training-accreditation/rrsr
https://www.livingworks.net/programs/asist
https://www.livingworks.net/programs/asist
https://www.qprinstitute.com
and it is the responsibility of policymakers,
health care professionals, and citizens to ad-
vocate change.
CONTRIBUTORS
J.M. Graves and J. L. Mackelprang are co-first authors.
J.M. Graves and S. E. Van Natta conceptualized the
study. S. E. VanNatta conducted the literature review, and
J.M. Graves and J. L. Mackelprang collected and summa-
rized final policy data. All authors contributed to the in-
terpretation of the findings, drafted the article, and provided
critical feedback and approval of the final article.
ACKNOWLEDGMENTS
The authors would like to acknowledge Sarah Schaub for
her assistancewithgraphics andGageDeMontHansen, Sc.
MPA, and Tracy A. Klein, PhD, FNP, ARNP, FAANP,
FRE, FAAN for their review of the article and feedback.
HUMAN PARTICIPANT PROTECTION
This study did not involve human participants and thus
institutional review board approval was not required.

41. REFERENCES
1. Kochanek KD, Murphy SL, Xu J, Tejada-Vera B.
Deaths: final data for 2014.Natl Vital Stat Rep. 2016;65(4):
1–122.
2. Curtin SC,Warner M, Hedegaard H. Increase in Suicide
in the United States, 1999–2014. Hyattsville, MD: Na-
tional Center for Health Statistics; 2016.
3. US Department of Health and Human Services. Na-
tional strategy for suicide prevention. 2012. Available at:
www.actionallianceforsuicideprevention.org/NSSP.
Accessed February 9, 2018.
4. De LeoD,Draper BM, Snowdon J, Kõlves K. Contacts
with health professionals before suicide: missed oppor-
tunities for prevention? Compr Psychiatry. 2013;54(7):
1117–1123.
5. Bolster C, Holliday C, Oneal G, Shaw M. Suicide
assessment and nurses: what does the evidence show?
Online J Issues Nurs. 2015;20(1):2.
6. Sudak D, Roy A, Sudak H, Lipschitz A, Maltsberger J,
Hendin H. Deficiencies in suicide training in primary care
specialties: a survey of training directors. Acad Psychiatry.
2007;31(5):345–349.
7. Bongar B, Harmatz M. Graduate training in clinical
psychology and the study of suicide. Prof Psychol Res Pr.
1989;20(4):209–213.
8. Dexter-Mazza ET, FreemanKA.Graduate training and
the treatment of suicidal clients: the students’ perspective.
Suicide Life Threat Behav. 2003;33(2):211–218.

42. 9. Schmitz WM, Allen MH, Feldman BN, et al. Pre-
venting suicide through improved training in suicide risk
assessment and care: an American Association of Suici-
dology Task Force report addressing serious gaps in US
mental health training. Suicide Life Threat Behav. 2012;
42(3):292–304.
10. US Department of Health and Human Services;
Office of the Surgeon General.National Strategy for Suicide
Prevention: Goals and Objectives for Action. Rockville, MD:
US Public Health Service; 2001.
11. Suicide PreventionResourceCenter. States. Available
at: http://www.sprc.org/states. Accessed October 9
2017.
12. Stuber J, Quinnett P.Making the case for primary care
and mandated suicide prevention education. Suicide Life
Threat Behav. 2013;43(2):117–124.
13. Ahmedani BK, Simon GE, Stewart C, et al. Health
care contacts in the year before suicide death. J Gen Intern
Med. 2014;29(6):870–877.
14. Luoma JB, Martin CE, Pearson JL. Contact with
mental health and primary care providers before suicide:
a review of the evidence. Am J Psychiatry. 2002;159(6):
909–916.
15. Silva C, Smith AR, Dodd DR, Covington DW,
Joiner TE. Suicide-related knowledge and confidence
among behavioral health care staff in seven states. Psychiatr
Serv. 2016;67(11):1240–1245.
16. Alexander DA, Klein S, Gray NM, Dewar IG, Eagles

43. JM. Suicide by patients: questionnaire study of its effect on
consultant psychiatrists. BMJ. 2000;320(7249):1571–1574.
17. Gulfi A, Castelli Dransart DA, Heeb JL, Gutjahr E.
The impact of patient suicide on the professional reactions
and practices of mental health caregivers and social
workers. Crisis. 2010;31(4):202–210.
18. Hendin H, Lipschitz A, Maltsberger JT, Haas AP,
Wynecoop S. Therapists’ reactions to patients’ suicides.
Am J Psychiatry. 2000;157(12):2022–2027.
19. McAdams CR III, Foster VA. Client suicide: its
frequency and impact on counselors. J Ment Health Couns.
2000;22(2):107–121.
20. Jahn DR, Quinnett P, Ries R. The influence of
training and experience on mental health practitioners’
comfort workingwith suicidal individuals.Prof Psychol Res
Pr. 2016;47(2):130–138.
21.Mackelprang JL, Karle J, Reihl KM,CashRE. Suicide
intervention skills: graduate training and exposure to
suicide among psychology trainees. Train Educ Prof
Psychol. 2014;8(2):136–142.
22.Michail M, Tait L, Churchill D. General practitioners’
clinical expertise in managing suicidal young people:
implications for continued education. Prim Health Care
Res Dev. 2017;18(5):419–428.
23. Chan SW, Chien WT, Tso S. Evaluating nurses’
knowledge, attitude and competency after an education
programme on suicide prevention. Nurse Educ Today.
2009;29(7):763–769.

44. 24. Berlim MT, Perizzolo J, Lejderman F, Fleck MP,
Joiner TE. Does a brief training on suicide prevention
among general hospital personnel impact their baseline
attitudes towards suicidal behavior? J Affect Disord. 2007;
100(1):233–239.
25. Fenwick CD, Vassilas CA, Carter H, Hague MS.
Training health professionals in the recognition, assess-
ment and management of suicide risk. Int J Psychiatry Clin
Pract. 2004;8(2):117–121.
26. Kishi Y, Otsuka K, Akiyama K, et al. Effects of
a training workshop on suicide prevention among
emergency room nurses. Crisis. 2014;35(5):357–361.
27.McNielDE, Fordwood SR,WeaverCM,Chamberlain
JR, Hall SE, Binder RL. Effects of training on suicide risk
assessment. Psychiatr Serv. 2008;59(12):1462–1465.
28. Santos JC, Simões RM, Erse MP, Façanha JD,
Marques LA. Impact of “+ Contigo” training on the
knowledge and attitudes of health care professionals about
suicide. Rev Lat Am Enfermagem. 2014;22(4):679–684.
29. PridemoreWA,ChamlinMB,Andreev E.Reduction
in male suicide mortality following the 2006 Russian
alcohol policy: an interrupted time series analysis. Am J
Public Health. 2013;103(11):2021–2026.
30. Grinshteyn E, Hemenway D. Violent death rates: the
US compared with other high-income OECD countries,
2010. Am J Med. 2016;129(3):266–273.
31. Miller M, Barber C, White RA, Azrael D. Firearms
and suicide in the United States: is risk independent of
underlying suicidal behavior? Am J Epidemiol. 2013;

45. 178(6):946–955.
AJPH LAW & ETHICS
768 Public Health Ethics Peer Reviewed Graves et al. AJPH
June 2018, Vol 108, No. 6
http://www.actionallianceforsuicideprevention.org/NSSP
http://www.sprc.org/states
Copyright of American Journal of Public Health is the property
of American Public Health
Association and its content may not be copied or emailed to
multiple sites or posted to a
listserv without the copyright holder's express written
permission. However, users may print,
download, or email articles for individual use.