Training Health Care Professionals in Suicide Assessment, Management, and Treatment

Suicide is a critical, ongoing public health crisis that may be exacerbated by the COVID-19 pandemic and its social and economic consequences. The rate of suicide has increased by more than 30% in half of all states in the United States since 1999 (1), with 47,511 deaths by suicide in 2019 (2). Most patients who died by suicide had contact with the health care system in the year before their deaths, whereas only about one-third had contact with a mental health service provider (3). Approximately three-quarters of patients had a visit with a primary care doctor in the year before their suicide (4), and 40% were seen in an emergency department (5). Mental health and substance use disorders are leading risk factors for suicide and are among the most common conditions treated in primary care settings. However, in a survey of primary care physicians in the United States, only 16% reported that their practice was “well prepared” to treat patients with these conditions (6).

Despite the availability of evidence-based screening tools, brief interventions, and comprehensive psychotherapies, implementation of these strategies in health care settings is uneven. The National Action Alliance for Suicide Prevention (https://theactionalliance.org) has recommended a standard of care to help health systems identify and support people who are at increased risk of suicide. The Joint Commission has published National Patient Safety Goals (https://www.jointcommission.org/standards/national-patient-safety-goals) to improve the quality and safety of care for those being treated for behavioral health conditions and identified as being at high risk of suicide. Some states recommend minimum standards of care for patients at elevated risk of suicide (7). Training health care providers to meet these standards is essential. Innovative approaches to providing high-quality, large-scale suicide prevention training for health care professionals (HCPs) are needed to enhance the quality of care for patients who are at risk of suicide.

Suicide Prevention Training in Washington State

Washington was the first U.S. state to require training for general medical and behavioral HCPs in suicide assessment, management, and treatment. According to the American Association of Suicidology (2), Washington is one of the states whose suicide rates are higher than the national average. This column provides context for Washington’s suicide prevention law, describes its implementation, and discusses results from a training program developed in response to the law.

Washington State House Bill 2366 (8), known as the Matt Adler Suicide Assessment, Treatment and Management Act, was passed by the legislature in 2012 by overwhelming margins and had the support of professional associations, veterans’ groups, and individuals personally affected by suicide. The law was named for a 40-year-old Seattle attorney named Matt Adler, husband of the lead author (J.S.) and father of two, who took his life in February 2011 while in treatment for severe depression and anxiety. Beginning in 2014, the law required behavioral health professionals, including licensed psychologists, social workers, marriage and family therapists, addiction specialists, and occupational therapists, to receive 6 hours of training every 6 years as part of their continuing education requirement to maintain their license.

The law was amended in 2014; effective 2017, all licensed HCPs, including chiropractors, dentists, pharmacists, dental hygienists, naturopaths, licensed practical nurses, registered nurses, advanced registered nurse practitioners, physicians and surgeons (allopathic and osteopathic), physician assistants (allopathic and osteopathic), physical therapists, and physical therapist assistants, were required to receive training. In legislative testimony, disagreement arose about adding a continuing education requirement for such a broad array of HCPs. The argument was made that most people who die by suicide never see a behavioral health professional; thus, equipping all HCPs to identify and treat patients at risk of suicide is vital. A major critique, delivered by the Washington State Psychiatric Association (which was not in favor of the amendment), was that training on its own would be unlikely to have an impact on suicide rates, because many health care settings have significant system-level barriers to implementing the recommended standard of care for suicide.

Although the law in Washington State was amended to include all HCPs, the training required for general medical health professionals was limited to one occurrence, in contrast to the requirement of completing training every 6 years for behavioral health professionals. According to the law, training must be established in consultation with experts and include content specific to veterans and the assessment of lethal means. For certain professions, identified by their disciplining authorities, training may be reduced to 3 hours.

The Washington State Department of Health is responsible for implementing the law and oversees the credentialing and licensure of general medical and behavioral HCPs. Implementation of the law by the Department of Health consists of establishing standards for training, reviewing curricula, maintaining a model list of training programs from which professionals can choose (9), and auditing professionals to ensure that they complete the training requirement. Because of the existing market for continuing education generated by the state licensure requirement, the legislature provided no funding to support the development of training, and the training was not always provided for free to professionals affected by the law.

According to the Department of Health, approximately 200,000 professionals were affected by the legislation. Of these, approximately 80% (N=160,000) were general medical HCPs and 20% (N=40,000) were behavioral HCPs. When Washington’s new suicide prevention law took effect, the coauthors found that large-scale options to train HCPs in suicide prevention for 6 hours were limited. Even though multiple in-person training programs designed for behavioral health professionals were available, it was necessary to create new training programs to accommodate the law’s more inclusive amendment. According to the Department of Health, as of May 2021, the state had 52 approved 6-hour suicide prevention training programs and 27 approved 3-hour training programs (9). Of note, the Department of Health did not require evaluation of these training programs.

The All Patients Safe Program

The University of Washington’s All Patients Safe (APS) (www.apsafe.uw.edu) training program was developed in response to the state legislation. It was initially developed to provide training to HCPs, free of charge, in two large health care systems (10). A federal grant from the Substance Abuse and Mental Health Services Administration was awarded to Washington State in 2020 that would expand by 6,000 the number of HCPs who could access the APS program free of charge by the end of 2022. HCPs complete APS online with a learning management system. The training program was built in modules so that participants could complete their training according to their schedules. It was informed by adult learning principles emphasizing opportunities for interactive, case-based learning and multimedia presentation of course materials, including videos of HCPs modeling high-quality care for patients with suicidal thoughts or behaviors and videos showing patient and family member perspectives. APS also supports HCPs in delivering a public health message to all patients about limiting access to lethal means and in integrating suicide prevention skills into daily interactions in patient care, and educates them about the need to advocate for protocol- and practice-level changes in their health care settings.

A program evaluation is built into APS to examine changes in HCPs’ knowledge and attitudes about suicide and perceived confidence in applying suicide prevention skills from before to after taking the course.

Participants and Methods

Between November 8, 2018, and December 30, 2020, in total 1,548 HCPs completed the 6-hour advanced APS training program, including a pretraining survey. Of those, 56% (N=873) completed a posttraining survey and were included in our sample. Participants were not required to respond to the posttraining survey to receive continuing education credit. The program evaluation was exempt from review by the University of Washington Human Subjects Division.

The average age of participants in our sample was 45 years (interquartile range 36–56), 66% (N=576) identified as female, 30% (N=262) identified as non-White, and 26% (N=227) reported working in primary care. Sixty percent (N=524) were affiliated with one of two large academic medical centers in Washington and received APS free of charge. The three most common types of HCPs who completed the surveys were doctors of medicine (N=463, 53%), registered nurses (N=96, 11%), and advanced registered nurse practitioners (N=79, 9%). Participants’ knowledge of and attitudes toward suicide and their confidence in treating patients at risk of suicide were examined by comparing pretest with posttest APS surveys. The McNemar test for dichotomous items and the McNemar-Bowker test of symmetry for Likert-scale items were used. Analyses were conducted with R, version 3.5.1.

Results

Responses to all 21 survey items indicated improvement in suicide prevention knowledge, attitudes, and confidence, and observed improvement was statistically significant for 20 of the 21 items. Although participants’ pretraining suicide knowledge was relatively high, their knowledge statistically significantly improved on the four knowledge items. The item with the greatest improvement was (response options of true or false), “More people die by suicide by firearm than all other means combined”: 77% (N=672) of participants answered correctly (true) on the pretest survey, and 94% (N=820) answered correctly on the posttest survey. Similarly, participants had statistically significant improvement in their attitudes about suicidal behavior after completing APS. Of particular interest, two questions assessed professionals’ attitudes about conversing with patients about firearm and medication storage, a key component of suicide prevention. Discomfort with having conversations about these prevention components decreased from before to after completing APS, and, as expected, survey respondents were more comfortable discussing medication storage than firearm storage. Regarding medication storage, 74% (N=646) initially disagreed with the statement, “I might offend my patients if I ask about their medication storage and disposal practices,” and 83% (N=725) responded in the same manner on the posttest. Regarding firearm storage, 67% (N=585) initially disagreed that “I might offend my patients if I ask about their firearms storage practices,” and 74% (N=646) responded in the same manner after completing APS. Statistically significant posttraining improvement was also observed for all eight items measuring participants’ confidence in applying suicide prevention skills (see the table in the online supplement to this column).

Discussion and Conclusions

These results indicate that it is possible to scale suicide prevention training for professionals in general medical and behavioral health care. It is unclear from this evaluation how long the beneficial effects of the APS training program on suicide prevention knowledge, attitudes, and confidence might last or whether the training program improves clinical practices. Understanding the potential utility of the APS training program in the context of specific health care settings, each of which has its own barriers to caring for patients with suicidal thoughts or behaviors, is a critical next step in research. Notably, another study, using self-reported data from the HCPs in our sample, found that protocols and policies that would reinforce the provision of high-quality, practice-level suicide prevention care were not well established (11).

After the passage of the Matt Adler Suicide Assessment, Treatment and Management Act, 17 states passed similar legislation, although none of those laws were as comprehensive as the original law passed in Washington. Those states followed Washington’s lead in either requiring or encouraging suicide prevention training for general medical or behavioral HCPs (11). No other state has yet extended the training requirement to include as comprehensive a list of HCPs as Washington State mandates. As states look to implement their suicide prevention laws or to pass new ones, lessons can be learned from Washington’s story.

It is possible to scale programs to train large numbers of HCPs in effective suicide prevention, and one such program appears to provide, at least in the short term, the benefits of improved knowledge of and attitudes toward suicide and confidence in treating patients at risk of suicide. States should make required training free to HCPs so that they will not feel penalized and should also ensure that the offered training is of high quality by requiring evaluation of all programs on their model lists. Furthermore, states should follow up with participants to ensure that general medical and behavioral HCPs are complying with the law and benefiting from the training they received. Washington State should survey all HCPs who are required to complete suicide prevention training to ascertain which program they completed, what they learned and retained from it, whether it affected their clinical practices, and, most important, what they perceive the state’s next steps should be to reduce the suicide rate.

Eight years after the law went into effect, Washington State’s suicide rate, compared with rates in other U.S. states, remains unchanged. Does this mean that the law was a failure? No, because increasing awareness of best practices is important. However, the absence of an effect on suicide rates does mean that requiring training for general medical and behavioral health care providers is not sufficient to reduce suicide rates, even though it is a necessary step. Health care systems must prioritize suicide prevention, including developing workflows for treating patients with suicidal thoughts or behaviors and supportive technologies such as electronic health records, to encourage uptake of evidence-based practices. Concerns about workforce shortages, a fragmented crisis delivery system, and inadequate reimbursement rates for treating individuals with suicidal thoughts and behaviors are also vitally important issues for policy makers to address. Considering the widespread cultural and societal factors that continue to drive up suicide rates, such as easy access to firearms and other lethal means, the influence of the Internet and social media on suicidal behavior, and the lasting social impacts of the pandemic, it is vital that suicide prevention training be implemented and that these other issues be addressed.