Healthcare policy

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 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- 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, 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: Reprints can be ordered at 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 & ETHICSmailto:janessa.graves@wsu.edu

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, 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 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: 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.

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 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 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


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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 (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, 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 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 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). 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.

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