What Would It Take to Prepare Health Care Professionals to Work With Suicidal Persons?

Consider for a moment what it would take for you to learn a new professional skill. And think about how long it will be before you can confidently—and competently—use it during your daily practice. In addition, imagine that the compelling reason for learning this skill is because you must discern who among your patients is considering killing themselves.

UPDATED SURVEY OF US STATES

The article by Graves et al. (p. 760) provides an updated survey of states that have issued or revised their suicide prevention plans (43 of 50 states) since the issuance of the 2012 second edition of the US National Strategy for Suicide Prevention.¹ It also documents those (10 with mandated training; 7 with encouragement) that require defined groups of health care professionals to undergo training to enhance skills in the recognition, evaluation, and management of persons with suicidal ideas or more well-formed plans. Taken as a measure of policy implementation, this is a relatively dismal performance given that suicide is the second leading cause of death for persons aged 15 to 34 years, the 10th leading cause of death overall, and, when combined with other forms of self-injury mortality (e.g., overdose-related deaths), the eighth leading cause of death for all ages.^2–4

DO PROGRAMS WORK?

The failure of many states to go beyond drafting an updated plan is compounded by the lack of evidence for how well currently mandated training programs prepare health providers to meet the challenges they may experience in the detection and initial assessment of potentially suicidal individuals and to thoughtfully respond and provide care or referral to more expert colleagues. We question whether these programs, including some that involve “evidence-based” offerings that are widely disseminated, meet the needs that we are asking our colleagues to fulfill. Do they transform basic clinical practices carried out in busy clinic, school, and community practice settings? Although the time spent training by a single professional may be relatively small, the cumulative investment in time and resources is large. What is the measured value? Does there need to be more time devoted to these efforts or different approaches to continuing professional education beyond what are, largely, didactic lecture-style approaches?

A DIFFICULT TASK

Inquiring about suicidal thoughts and plans is difficult, often frightening, and certainly anxiety-provoking for the less experienced. Having worked with many medical and graduate students, residents of multiple disciplines, nurses, and social workers, as well as community partners, we have seen repeatedly how difficult this task can be. Asking mental health professionals to regularly screen patients in their caseloads can rouse fundamental concerns among a considerable number.⁵ We often have heard versions of a clinical paradox: What do I do if I find something? What do I do if my patient screens negative and then kills himself shortly after? Beyond these concerns, we still encounter the recurring myth that asking about suicide will create the thought, despite evidence to the contrary.⁶ Declaring that asking directly will not foster new ideas or plans does not uniformly allay fears.

Conducting an effective, alliance-building interview requires practice and feedback. Current evidence-based curricula have shown increased knowledge, enhanced attitudes, and, for some, greater confidence, but there is scant evidence that they actually change clinician behaviors in real-world settings.

SETTING GOALS

What do we need before researchers or policy leaders survey the field again? Certainly, there must be a higher level of expectation that current professionals will participate in needed training—in all 50 states! Would we expect physicians, for example, to be unprepared to deal with common patient illnesses, such as pneumonia, influenza, or diabetes? At the same time, state education departments need to require effective training during the introductory education phase of professionals’ careers (e.g., medical and nursing school, social work training) with documentation of achieved competencies.

If suicide prevention really is a public health problem, we should expect our legislators to take their part in ensuring that patients, families, and communities can place their confidence in primary care providers, social workers, nurses and nurse practitioners, psychiatrists, and clinical and school psychologists to have the skills needed to screen, assess, and initially help suicidal patients. Although it is time to move beyond the veneer of training that is expected for working professionals in those states that have mandates, we are uncertain whether there yet is sufficient outrage to demand such changes. However such changes come about, we recall the response to the question, “How do you get to Carnegie Hall?” Practice, practice, practice. We await the time when this admonition is commonly accepted as a key element for preventing death from suicide and other adverse self-injury outcomes that share common risks.