Health Psychology © 2013 American Psychological Association

2014, Vol. 33, No. 2, 110 –119 0278-6133/14/$12.00 http://dx.doi.org/10.1037/a0031062

An Assessment of Suicide-Related Knowledge and Skills Among

Health Professionals

April R. Smith Caroline Silva

Miami University Florida State University

David W. Covington Thomas E. Joiner, Jr.

Magellan Health Services of Arizona, Phoenix, Arizona Florida State University
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Objective: The present studies sought to examine the association between gatekeeper training and suicide
knowledge among a diverse set of health care workers (case managers, clinicians, administrators, nurses,
physicians, support staff). An additional aim of the current studies was to investigate knowledge about
suicide among health care workers as well as their confidence in their training and skills. Method: A
naturalistic and uncontrolled group comparison study of two large groups (n ⫽ 1,336 and 1,507) of
community health workers was conducted by having participants complete a brief online survey that
assessed suicide-related knowledge, as well as confidence in training, skills, and support. Results: In
Study 1, participants with Applied Suicide Intervention Skills Training (ASIST) outperformed those
without ASIST training in terms of their knowledge about suicidal behavior and their confidence in their
skills. In Study 2, participants with Question, Persuade, and Refer (QPR) training outperformed those
with Essential Learning’s Suicide Prevention (Online) training and those with No Training on suicide
knowledge items; both QPR and Online trained workers reported greater confidence in their skills than
workers with No Training. Across both studies, physicians and clinicians tended to score the highest on
suicide knowledge and skills items. Conclusions: Overall, health care workers appear to be knowledge-
able about suicidal behavior, but there are some specific gaps in their knowledge, such as the rates of
suicide in special populations. Participants with ASIST and QPR training demonstrated greater knowl-
edge and skills related to suicidal behavior as compared with participants without gatekeeper training.

Keywords: suicide, gatekeeper training, suicide risk, health care

In the United States alone someone dies by suicide every 15
minutes. This translates to approximately 101 deaths per day and
more than 36 thousand deaths per year as of 2009 (Department of
Health and Human Services [DHHS], 2012). This is more than
twice the number by homicide, and makes suicide the 10th leading
cause of death in the United States (DHHS, 2012). Importantly,
one of the most effective ways to combat serious public health
problems, like suicide, is to increase knowledge about risk factors,
assessment procedures, and treatment options. Indeed, in 1999 the
Surgeon General’s call to action to prevent suicide included rec-
ommendations for awareness and intervention. Recommendations
for awareness (i.e., to “appropriately broaden the public’s aware-
ness of suicide and its risk factors”) included the following: (1)
promoting public awareness of suicide as a preventable public
health problem and making facts about suicide, and its risk factors
This article was published Online First February 4, 2013.
April R. Smith, Department of Psychology, Miami University; Caroline
Silva and Thomas E. Joiner, Jr., Department of Psychology, Florida State
University; David W. Covington, Magellan Health Services of Arizona,
Phoenix, Arizona.
Correspondence concerning this article should be addressed to April R.
Smith, Miami University, Department of Psychology, 90 N. Patterson,
Oxford, OH 45056. E-mail: aprilsmith@miamioh.edu
110
and prevention approaches, available to the public and health care
providers; (2) expanding awareness of and resources for suicide
prevention programs within communities; and (3) developing and
implementing strategies to reduce stigma associated with mental
illness (U.S. Public Health Service, 1999).
Despite the importance of having health workers well trained on
suicide best practices and the Surgeon General’s call to action,
knowledge about suicidal behavior and its assessment and treat-
ment, even among health care professionals, has tended to lag
behind related research in the field. Gaps between research and
practice may be related to lack of appropriate training. For exam-
ple, only one of three high school counselors surveyed felt that he
or she could recognize a student at risk for suicide (King, Price,
Telljohann, & Wahl, 1999). Dexter-Mazza and Freeman (2003)
found that only half of the psychology interns surveyed reported
receiving formal training in assessing and managing suicidal cli-
ents. Further, a group of psychiatry residents (a third of whom are
expected to experience a client’s suicide during their training)
reported that only one quarter of their training programs offered
skill development workshops pertaining to suicide (Ellis, Dickey,
& Jones, 1998). Training directors from various medical schools
have also indicated inadequacies in their programs’ suicide man-
agement training (Sudak, Roy, Sudak, Lipschitz, Maltsberger, &
Hendin, 2007). This is particularly notable given that close to 50%
 AN ASSESSMENT OF SUICIDE-RELATED KNOWLEDGE
of those who die by suicide will have seen their primary care
physician in the month before their death (Luoma, Martin, &
Pearson, 2002).
Importantly, the theory of planned behavior1 (Ajzen, 1985) posits
that human behavior is guided by three considerations leading to the
formation of intention and then behavior: (1) beliefs about likely
outcomes and evaluations of behaviors (behavioral beliefs); (2) be-
liefs about normative expectations of others and motivation to comply
(normative beliefs); and (3) beliefs about the presence and power of
factors that may facilitate or impede performance of the behavior
(control beliefs). Increasing awareness of suicide-related facts, risk
factors, and prevention approaches may increase knowledge and, in
turn, confidence in skills related to suicide prevention via influencing
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behavioral, normative, and control beliefs. Thus, increases in knowl-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
edge and confidence in skills may make it more likely that an
individual will engage in suicide prevention behaviors such as suicide
risk assessments and referrals.
Recent attempts have been made to improve access to suicide
training by offering suicide training programs, such as Applied Sui-
cide Intervention Skills Training (ASIST; LivingWorks Educational
Inc., 2005), Question, Persuade, and Refer (QPR; Quinnet, 1995), and
online suicide prevention programs to health care workers. These
types of training programs are commonly referred to as gatekeeper
training, as they are geared toward people who are likely to have
contact with individuals at risk for suicide (Isaac et al., 2009). Gate-
keeper training programs teach trainees to identify risk factors for
suicide and aim to increase trainees’ knowledge about suicidal be-
havior and improve skills related to management of suicidal individ-
uals. In their review of gatekeeper training programs, Isaac and
colleagues (2009) found that these programs are associated with
increases in suicide-related knowledge and skills.
However, of the relatively few studies examining the effectiveness
of gatekeeper training, most have relied on populations of either
school staff or physicians. Thus, the purpose of this exploratory,
uncontrolled naturalistic study was twofold: (1) to examine general
knowledge about suicide among a diverse array of health care workers
and (2) to investigate the impact of gatekeeper training on health care
workers’ suicide-related knowledge and skills. As described below,
we have obtained information from two large and diverse sets of
health care professionals for this purpose. We predicted that gate-
keeper training would be associated with more knowledge about
suicidal behavior and more confidence in one’s skills in dealing with
a suicidal individual. Additionally we predicted that health workers
with more overall training, like physicians and clinicians, would
evidence more knowledge and skills than health care workers with
less training. Finally, as an exploratory aim, we examined whether
there was an interaction between professional group and gatekeeper
training to determine whether gatekeeper training was particularly
helpful for certain types of health care workers.
Study 1
Method
Procedure. Participants were recruited via email. Specifi-
cally, the chief executive officers (CEOs) of the 35 largest publicly
funded community behavioral health care providers in Phoenix
were notified about the study, which was survey based, and were
asked to share the survey information with their employees.2
111
Target audiences included all direct care staff, administrators, and
support staff. All of the CEOs passed along the information about
the study to their employees, with at least one employee in each
agency participating. Participants were informed that the survey
was meant to “assess a baseline regarding perception of training,
skills, and supports to work with those at risk of suicide” and that
results would be used to inform future training opportunities.
Participants were not offered training; rather, they were able to
indicate whether they had received a particular type of suicide
training. Participation was voluntary and confidential. Participants
who chose to provide their e-mail addresses were entered into a
drawing for a $100 gift card. Participants completed the survey
online via a secure website. All procedures were approved by the
university’s Institutional Review Board.
Participants. Our sample consisted of 1,337 skilled workers
from Maricopa County, Arizona. The participants identified their
professional roles as follows: 26.3% Support staff, 25.9% Clini-
cian, 24.2% Case manager, 13.6% Administrator, 6.2% Nurse,
3.8% Physician. The participants endorsed working with the fol-
lowing types of populations: adults (72.4%), individuals with
severe mental illness (58.9%), individuals with general mental
health/substance abuse problems (34.7%), children and adoles-
cents (22.9%), and 10.6% of participants reported that they worked
in administration only. The majority of respondents (55.5%) re-
ported that they had not worked with a consumer who ended his or
her life by suicide, 37.1% reported they had worked with at least
one person who had ended his or her life by suicide, and 7.4% did
not know.
Participants were asked whether they had or had not received
ASIST training; participation in other types of suicide training
programs was not assessed in the current study. Forty percent of
study participants self-reported that they had ASIST training. The
percentages of health care workers who received ASIST training
were as follows: case managers (60%), clinicians (39%), physi-
cians (12%), nurses (10%), administrators (44%), and support staff
(32%). All participants completed the survey within a year of
completing ASIST training. There were no significant differences
between the ASIST versus non-ASIST group with respect to
experience working with adults, clients with severe mental illness,
administration only, or a client who died by suicide.
ASIST consists of a 2-day (14 hour) workshop in which partic-
ipants are trained to provide “suicide first aid.” The ASIST work-
shop is led by a team of at least two registered trainers (i.e., those
who have completed a 5-day ASIST Training for Trainers [T4T]
course), with one trainer per 7 to 15 participants. Specifically,
participants are taught to recognize when someone may be at risk
for suicide and how to respond in a manner that increases a
suicidal individual’s immediate safety and links him or her to a
1
See Armitage and Conner (2001) for a review of empirical evidence
related to the theory.
2
In both studies, we selected the network of community behavioral
healthcare agencies that contract with state mental health and addiction
services authorities to provide “clinical home” services. In Arizona, these
primary behavioral healthcare agencies contract with Magellan Health
Services in its role as the Regional Behavioral Health Authority (who in
turn contracts with the Arizona Department of Health Services/Division of
Behavioral Health Services). In Georgia, these primary community mental
health centers are “core providers” for the state of Georgia’s Department of
Behavioral Health and Developmental Disabilities (DBHDD).
 112 SMITH, SILVA, COVINGTON, AND JOINER
variety of community resources. ASIST training uses simulations
to improve skill development and aims to improve trainee attitudes
toward suicide intervention. ASIST is designed to work best as
part of a community-based comprehensive approach to reducing
suicide risk. A workgroup for the National Suicide Prevention
Lifeline studied several models and selected ASIST as the best fit
and most effective model for implementing in the national network
of crisis centers for training staff (D. W. Covington, personal
communication, November 20, 2009). Additionally, 2% of partic-
ipants had ASIST T4T. As mentioned above, ASIST T4T is a
5-day course that prepares participants to be trainers of ASIST
workshops.
Measures.
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Demographics. A brief demographic form asked participants
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to report their professional role and the populations with which
they worked. Ethnic/racial data were not collected.
Suicide Knowledge and Skills Questionnaire. This 13-item
survey questionnaire was created by the authors to assess partici-
pants’ knowledge about suicidal behavior and comfort dealing
with suicidal clients. Items were based on the Suicide Opinions
Questionnaire (SOQ; Domino, Gibson, Poling, & Westlake, 1980).
The SOQ is a 100-item measure that consists of eight subscales
derived using expert consensus as well as empirical tests for
internal consistency (Domino, MacGregor, & Hannah, 1988). The
SOQ has been found to have excellent test–retest reliability (Dom-
ino, 1996). The nature of our study required a shorter assessment;
thus, we chose nine items that paralleled items on the SOQ. The
survey comprised two subscales: Suicide Knowledge and Suicide
Skills. The Suicide Knowledge subscale comprised nine items
written to reflect either a truth or falsehood about suicide. The
Kuder–Richardson Formula 20 (KR20) was used to calculate
reliability for this subscale because these responses were binary
and the level of difficulty of the questions varied (␣ ⫽ .50). The
low alpha reflects that the knowledge items were miscellaneous
and thus would not be expected to hang together well.
The Suicide Skills subscale (␣ ⫽ .81) comprised four items that
assessed respondents’ comfort dealing with suicidal clients in
terms of their confidence in their training, skills, and supervision
they received. Example items include, “I am comfortable asking
direct and open questions about suicide,” “I have received the
training I need to engage and assist those with suicidal desire
and/or intent.” Participants were given the following response
options for these questions: Completely agree, Agree, Don’t know,
Disagree, Completely disagree.
Data analytic plan. We compared the following groups’ per-
formance on the survey: case managers (n ⫽ 324), clinicians
(n ⫽ 346), administrators (n ⫽ 182), nurses (n ⫽ 83), physicians
(n ⫽ 51), and support staff (n ⫽ 350). To compare the groups’
performance on the Suicide Knowledge portion of the survey, we
calculated the overall average percentage of correct responses per
item and each groups’ average percentage of correct responses per
item. For each item, we then subtracted the overall survey average
from each groups’ average to yield a difference from the mean
percentage. Next, we computed 95% confidence intervals around
the percentage difference from the mean using procedures de-
scribed by Lane (2007).
We also broke the groups into those with ASIST training (com-
prising trainees and trainers, n ⫽ 799) and those without ASIST
training (n ⫽ 537) and compared these groups’ percentage differ-
ence from the mean. When statistically significant differences
between groups were indicated (by nonoverlapping confidence
intervals), we calculated effect sizes for the pairwise comparison
of differences of percentages using Cohen’s (1992) formula for h.
This formula is the difference between the acrsine transformation
of the percentages. The sizes of h are as follows: small, .20 –.50;
medium, .50 –.80; large, ⬎.80. Additionally, we ran a series of
ANOVAs to compare the professional groups’ performance on the
survey and the ASIST and non-ASIST groups’ performance on the
survey, as well as to examine potential interactions between pro-
fessional group and training. Further, we looked at the correlation
between Suicide Knowledge and Suicide Skills to examine
whether more knowledge was associated with greater confidence
in one’s skills.
Results
Suicide Knowledge Questions. See Table 1 for the overall
responses to the survey items broken down by professional group
and training group. The ASIST group performed significantly
worse than the non-ASIST group on Item 1, h ⫽ .03. The ASIST
group performed significantly better than the non-ASIST group on
Items 2– 6, 8 –9, h ⫽ .01–.11. There was not a significant differ-
ence between the ASIST and non-ASIST groups on Item 7.
Suicide Knowledge total score. The ASIST group performed
significantly higher on the Suicide Knowledge total score than did
the non-ASIST group, F(1, 1335) ⫽ 30.79, p ⬍ .001. A one-way
ANOVA revealed that there were significant differences between
the professional groups on their Suicide Knowledge total scores,
F(5, 1331) ⫽ 18.56, p ⬍ .001. Post hoc Tukey’s HSD tests showed
that physicians did better than case managers, (p ⬍ .002), admin-
istrators (p ⬍ .04), and support staff (p ⬍ .001); clinicians did
better than case managers (p ⬍ .04) and support staff (p ⬍ .001);
additionally, nurses (p ⬍ .001), administrators (p ⬍ .001), and case
managers (p ⬍ .001) did better than support staff.
Suicide Skills total score. The ASIST group had significantly
higher scores on the Suicide Skills subscale than did the non-
ASIST group (higher scores indicate greater confidence in skills),
F(1, 1333) ⫽ 298.21, p ⬍ .001. A one-way ANOVA revealed that
there were significant differences between the groups on their
Suicide Skills scores, F(5, 1329) ⫽ 30.58, p ⬍ .001. Follow-up
comparisons showed that clinicians reported more skills than ad-
ministrators (p ⬍ .005) and support staff (p ⬍ .001); physicians
reported more skills than administrators (p ⬍ .003) and support
staff (p ⬍ .001); additionally, nurses (p ⬍ .001), case managers (p
⬍ .001), and administrators (p ⬍ .001) reported more skills than
support staff.
Overall survey results. Next we looked to see whether there
was an interaction between training (ASIST vs. non-ASIST) and
professional group (physician, nurse, administrator, clinician, case
manager, support staff) on the Suicide Knowledge and Suicide
Skills scores. The interaction for the Suicide Knowledge scores
was not significant, F(5, 1325) ⫽ 0.97, p ⬍ .44. However, the
interaction for the Suicide Skills scores was significant, F(5,
1325) ⫽ 4.89, p ⬍ .001. Post hoc Tukey’s HSD tests revealed that
the ASIST training was associated with significantly higher Sui-
cide Skills scores for support staff (p ⬍ .001), case managers (p ⬍
.001), administrators (p ⬍ .001), and clinicians (p ⬍ .001). ASIST
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Table 1
Arizona Skilled Workers Performance Compared With the Average on the Suicide Knowledge Survey

Mean % Non-ASIST ASIST Case manager Clinician Physician Nurse Admin Support staff
correct (n ⫽ 537) (n ⫽ 799) h (n ⫽ 324) (n ⫽ 346) (n ⫽ 51) (n ⫽ 83) (n ⫽ 182) (n ⫽ 350)

1. Few people want to kill 67.4% 1.3% ⫺1.1% ⫺2.1% ⫺6% ⫺8.9% 3.2% ⫺5% 9.6%
themselves (F) (0.6–2.0) (⫺1.9–⫺0.4) .03 (⫺3.6–⫺0.6) (⫺3.5–⫺8.5) (⫺16.6–⫺1.2) (⫺0.5–6.9) (⫺8.2–⫺1.2) (6.4–12.8)
2. Youth ages 10–24 have a ⫺4.5% 6.8% 0.1% 9.3% 19.6% 4.2% 5.0% ⫺14.0%
significantly greater risk of 52.1% (⫺5.8–⫺3.2) (4.9–8.7) .11 (⫺0.2–0.4) (6.2–12.4) (8.9–30.3) (⫺0.06–8.4) (1.8–8.2) (⫺17.8–⫺10.2)
suicide than individuals aged 65
and older (F)
3. The rate of suicide among those 35.1% ⫺0.2% 0.6% ⫺1.1% 2.7% 27.9% 1.3% ⫺0.5% ⫺7.4%
with severe mental illness is 6 (⫺.4–⫺0.1) (0.01–1.2) .01 (⫺2.2–.02) (1.0–4.4) (15.8–40.0) (⫺1.1–3.7) (⫺1.5–0.5) (⫺10.2–⫺4.6)
times the general population (T)
4. If a person is serious about 90.6% ⫺0.8% 1.7% ⫺0.5% 1.1% ⫺1.9% ⫺0.1% 2.8% ⫺1.8%
suicide, there is little that can be (⫺1.4–⫺0.2) (0.7–2.7) .04 (⫺1.3–0.3) (⫺0.02–2.2) (⫺5.6–1.8) (⫺0.8–0.5) (0.4–5.2) (⫺3.2–⫺0.4)
done to prevent it (F)
5. If you talk to a consumer about 93.3% ⫺1.7% 2.4% 1.3% 2.4% 6.7% 4.3% 0.2% ⫺5.6%
suicide, you may inadvertently (⫺2.5–⫺0.8) (1.2–3.6) .09 (0.08–2.5) (0.8–4.0) (⫺0.03–13.4) (⫺0.01–8.6) (⫺0.4–0.8) (⫺8.1–⫺3.1)
give them permission to seriously
consider it (F)
6. Depression indicates a suicide 75.6% ⫺2.8% 3.9% ⫺1.0% 3.1% 9.3% ⫺1.5% 6.2% ⫺4.7%
risk (T) (⫺3.9–⫺1.7) (2.4–5.4) .08 (⫺2.1–0.07) (1.2–5.0) (1.5–17.1) (⫺4.1–1.1) (2.7–9.7) (⫺7.0–⫺2.4)
7. Suicide is always unpredictable 83.2% 0.2% 0.4% ⫺3.2% 7.8% 7.5% 8.9% 5.1% ⫺4.6%
(F) (⫺0.09–0.5) (⫺0.08–0.9) ns (⫺5.1–⫺1.3) (4.9–10.7) (0.4–14.6) (2.8–15.0) (1.9–8.3) (⫺6.9–⫺2.3)
8. Suicidal people want to die (F) 90.6% ⫺1.3% 2.3% 0.9% 2.7% 1.9% ⫺1.4% 0.7% ⫺1.2%
(⫺2.0–⫺0.6) (1.2–3.4) .06 (⫺0.1–1.9) (1.0–4.4) (⫺1.8–5.6) (⫺3.9–1.0) (⫺0.5–1.9) (⫺2.4–⫺0.02)
9. Individuals with BPD frequently 52.6% ⫺2.4% 3.8% ⫺3.8% 2.8% 8.9% 3.2% 6.6% ⫺0.4%
AN ASSESSMENT OF SUICIDE-RELATED KNOWLEDGE

discuss or gesture suicide but do (⫺3.4–⫺1.4) (2.3–5.3) .06 (⫺5.9–⫺1.7) (1.0–4.6) (1.2–16.6) (⫺0.5–6.9) (3.0–10.2) (⫺1.1–0.3)
not really intend to kill
themselves; instead they intend
to provoke or manipulate others
(F)
Note. 95% confidence intervals are contained within the parentheses.
113
 114 SMITH, SILVA, COVINGTON, AND JOINER
training was not associated with higher Suicide Skills scores for
nurses, p ⬍ .10, or physicians, p ⬍ .89.
Performance on the Suicide Knowledge subscale was signifi-
cantly correlated with the Suicide Skills subscale, such that more
knowledge was associated with greater confidence in one’s skills,
r ⫽ .32, p ⬍ .001.
Discussion
As predicted we found that those with ASIST training had more
suicide-related knowledge and confidence than those without
ASIST training. These findings are consistent with previous re-
search which has found that gatekeeper training improves knowl-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
edge and attitudes about suicide from pre to posttest (e.g., Tomp-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
kins, Witt, & Abraibesh, 2010) and longitudinally (e.g., Keller et
al., 2009). However, contrary to study hypotheses we found that
the ASIST group performed worse than the non-ASIST group on
Item 1 (“Few people want to kill themselves”) and that there was
no difference between the groups on Item 7 (“Suicide is always
unpredictable”). It is possible that the ASIST group underper-
formed on Item 1 because of ASIST’s focus on direct intervention
as opposed to suicide statistics (approximately half of the training
is related to intervention). The lack of difference between groups
on Item 7 may be attributable to a ceiling effect as both groups
performed very well on this item.
Hearteningly, the majority of the respondents answered most of
the survey questions correctly and Suicide Knowledge was signif-
icantly related to Suicide Skills, indicating that the more health
care workers know about suicide the more confident they feel in
working with suicidal individuals. Physicians and clinicians dem-
onstrated more suicide-related knowledge than case managers, and
support staff scored significantly lower than all the other profes-
sional groups. Clinicians and physicians also reported more con-
fidence in their suicide skills than administrators, and again sup-
port staff reported significantly less confidence in their skills than
all the other groups. There was a significant interaction for suicide
skill scores, such that ASIST training was associated with higher
Suicide Skills scores for case managers, clinicians, support staff,
and administrators.
Some important limitations of the study should be noted. First,
the survey that participants completed is not a validated assess-
ment of suicide-related knowledge. However, our survey was
based on a validated measure of knowledge about suicide (SOQ,
Domino, Gibson, Poling, & Westlake, 1980). Additionally, the
issue of sample bias must be considered given that: (1) the respon-
dents were from one particular geographic location, and (2) those
who participated may have been more interested and/or knowl-
edgeable about the topic than those who chose not to participate.
Relatedly, attendance for the ASIST training was self-selected,
thus people who attended ASIST training may have been more
interested and knowledgeable about suicide to begin with. Simi-
larly, some individuals may be expected to have more knowledge
and confidence as a result of occupational functions and exposure
to suicidal clients. Further, this study did not use an experimental
design to examine the effects of the ASIST program, thereby
limiting the strength of the conclusions that can be drawn. Despite
these limitations, the study possesses several strengths, such as the
inclusion of a large community sample of health care workers,
representing a wide array of health care fields.
Taken together, these findings suggest that certain groups, such
as support staff, may be important targets for ASIST training.
Gatekeeper training, such as ASIST, has been found to improve
skills and knowledge of other groups, such as school personnel
(e.g., Tompkins, Witt, & Abraibesh, 2010); however, to our
knowledge this is the first study to show that ASIST training was
positively associated with knowledge and skills across a variety of
health care workers, including physicians, clinicians, and admin-
istrators.
Study 2
The purpose of Study 2 was to address some of the limitations
of Study 1 and to examine the generalizability of the Study 1
findings. Specifically, in Study 2 we sought to partially address the
sample bias limitation of the first study by including participants
from a different region of the United States. Further, in Study 2 we
investigated different gatekeeper training programs and additional
professional types. The aims of Study 2 were similar to those of
Study 1.
Method
Procedure. Participant recruitment followed the procedures
of Study 1. In this study, the CEOs of 30 community behavioral
health care providers across the state of Georgia were notified
about the survey and asked to forward it on to their employees. As
with Study 1, all of the CEOs passed along the information about
the study to their employees, with at least one employee in each
agency completing the survey. Participants were not offered train-
ing, but rather, were able to indicate whether they had received
particular types of suicide training in the survey.
Participants. Our sample consisted of 1,507 skilled workers
from Georgia. The participants identified their professional roles
as follows: 27.4% Paraprofessional/nonlicensed staff, 15.6% Pro-
fessional counselor (LPC, LAPC), 14.1% Support staff, 8.3%
Nurse, 8.3% Social worker (LCSW, LMSW), 8.2% Administrator,
1.9% Physician, and 16.2% Other. The participants endorsed
working with the following types of populations: adults (71.8%),
seniors (28.9%), children and adolescents (40%), and 12.1% of
participants reported that they worked in administration only. Most
respondents (66.3%) reported that they had not worked with a
consumer who ended his or her life by suicide, 24.3% reported
they had worked with at least one person who had ended his or her
life by suicide, and seven percent did not know.
Of these participants, 40.4% self-reported having received Es-
sential Learning’s Suicide Prevention (Online) training only, 4.4%
Question, Persuade, and Refer (QPR) training only, and 55.2%
reported receiving neither QPR nor Online training. Only partici-
pants who had received one of the gatekeeper training modalities
(Online, QPR), or neither Online nor QPR, were selected for the
analyses. The percentages of health care workers who received
either QPR or Online training were as follows: paraprofessionals
(76%), professional counselors (39%), social workers (32%), phy-
sicians and nurses (28%), administrators (34%), and support staff
(32%). There were no significant differences between the groups
with respect to experience working with adults or clients with
severe mental illness. Those with QPR training were more likely to
have worked with someone who died by suicide as compared with
 AN ASSESSMENT OF SUICIDE-RELATED KNOWLEDGE
the Online and No Training groups; additionally, the No Training
group was more likely to work in administration only as compared
with the Online group.
Essential Learning provides online learning, staff compliance
training, and continuing education to human service organizations
and practitioners. Essential Learning’s online module on Suicide
Prevention (code: SP101GA; 2 Credit Hours) discusses the prev-
alence and risk factors associated with suicide, as well as the
relationship between depression and suicide. The course also cov-
ers signs and symptoms of suicidal behavior and effective staff
responses and interventions for clients at risk for suicide. This
module is part of the standard training requirement in suicide risk
assessment for behavioral health paraprofessionals set by the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Georgia Department of Behavioral Health and Developmental
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Disabilities (DBHDD). However, other behavioral health practi-
tioners and staff registered with Essential Learning are allowed to
complete this online training module as well.
The QPR Gatekeeper Training for Suicide Prevention program
(1 hour) teaches participants to recognize the warning signs of a
suicide crisis and how to “question, persuade, and refer” someone
for further assessment and care. QPR Gatekeeper Training is
usually taught face-to-face by QPR Certified Gatekeeper Instruc-
tors (i.e., those who complete at least 8 hours of specialized
training in the QPR suicide prevention method and approach). The
QPR institute also offers the QPR Suicide Triage Training pro-
gram (8 hours), aimed at individuals who might encounter suicidal
individuals during the course of their work. This program is
designed to standardize detection, assessment, documentation and
management of patients at elevated risk for suicidal behaviors. All
trainings involve lectures, discussion, and role-playing to build
skills.
Measures. Participants were asked to complete a similar de-
mographic form to that used in Study 1. Participants were also
asked to complete the same Suicide Knowledge and Skills Ques-
tionnaire used in Study 1.
Data analytic plan. We compared the following groups’ per-
formance on the survey: paraprofessionals/ nonlicensed staff
(n ⫽ 413), clinicians (n ⫽ 235), support staff (n ⫽ 212), nurses
(n ⫽ 125), social workers (n ⫽ 125), administrators (n ⫽ 124), and
physicians (n ⫽ 29). We also examined the groups based on type
of training received: those with Online training only (n ⫽ 609),
those with QPR training only (n ⫽ 66), and those with neither
Online nor QPR training (No Training; n ⫽ 832). Similar data
analytic procedures to those used in Study 1 were employed.
Results
Suicide Knowledge Questions. See Table 2 for the overall
responses to the survey items broken down by professional group
and training group. Nonoverlapping confidence intervals indicate
significant differences between the groups; effect sizes are re-
ported in Table 3.
Suicide Knowledge total score. A one-way ANOVA indi-
cated that there were significant differences between the training
types on participants’ Suicide Knowledge total score (higher
scores indicate greater knowledge), F(2, 1429) ⫽ 9.13, p ⬍ .001.
Post hoc Tukey’s HSD tests revealed that participants with QPR
training did significantly better than those with Online training
(p ⬍ .001) and No Training (p ⬍ .001). There was no significant
115
difference between participants with Online training and No Train-
ing on total Suicide Knowledge scores, p ⬍ .43.
A one-way ANOVA revealed that there were significant differ-
ences between the professional groups on their Suicide Knowledge
scores, F(6, 1251) ⫽ 14.33, p ⬍ .001. Post hoc tests revealed that
physicians did significantly better than support staff (p ⬍ .001).
Social workers did significantly better than paraprofessionals (p ⬍
.001) and support staff (p ⬍ .001). Clinicians also did significantly
better than paraprofessionals (p ⬍ .001) and support staff (p ⬍
.001). Finally, nurses (p ⬍ .001), administrators (p ⬍ .005), and
paraprofessionals (p ⬍ .003) also did significantly better than
support staff.
Suicide Skills total score. A one-way ANOVA indicated that
there were significant differences between the training types on
participants’ Suicide Skills scores, F(2.1441) ⫽ 24.63, p ⬍ .001.
Follow-up pairwise comparisons revealed that participants with no
training reported significantly less confidence in their skills than
participants with QPR training (p ⬍ .001) and participants with
Online training only (p ⬍ .001). Moreover, participants with QPR
training only reported significantly greater confidence in their
skills than those with Online training only, p ⬍ .001.
A one-way ANOVA revealed that there were significant differ-
ences between the professional groups on their Suicide Skills
scores, F(6, 1279) ⫽ 39.77, p ⬍ .001. Follow-up pairwise com-
parisons revealed that physicians reported significantly greater
confidence in their skills than paraprofessionals (p ⬍ .01), admin-
istrators (p ⬍ .001), and support staff (p ⬍ .001). Clinicians
reported significantly greater confidence in their skills than para-
professionals (p ⬍ .001), nurses (p ⬍ .002), administrators (p ⬍
.001), and support staff (p ⬍ .001). Social workers also reported
significantly greater confidence in their skills than paraprofession-
als (p ⬍ .001), administrators (p ⬍ .001), and support staff (p ⬍
.001). Nurses also reported significantly greater confidence in their
skills than administrators (p ⬍ .01) and support staff (p ⬍ .001).
Paraprofessionals (p ⬍ .001) and administrators (p ⬍ .01) also
reported significantly greater confidence in their skills than sup-
port staff.
Overall survey results. Next we looked to see whether there
was an interaction between training (QPR vs. Online vs. No
training) and professional group (paraprofessional, clinicians, so-
cial worker, physician, nurse, administrator, support staff) on the
Suicide Knowledge and Suicide Skills scores. The interaction for
the Suicide Knowledge scores was not significant, F(11, 1192) ⫽
1.29, p ⬍ .22. However, the interaction for the Suicide Skills
scores was significant, F(11, 1219) ⫽ 3.59, p ⬍ .001. Post hoc
tests revealed that Online training was associated with higher
Suicide Skills scores for paraprofessionals, as compared with No
Training, p ⬍ .003. On the other hand, QPR training was associ-
ated with higher Suicide Skills scores for administrators as com-
pared with Online training, (p ⬍ .01) and no training (p ⬍ .01).
Similarly, QPR training was associated with higher Suicide Skills
scores for support staff as compared with Online training (p ⬍ .05)
and no training (p ⬍ .001). However, online training was also
associated with higher Suicide Skills scores for support staff as
compared with No Training. Type of training received was not
associated with difference in Suicide Skills scores for clinicians,
social workers, physicians, or nurses.
Performance on the Suicide Knowledge subscale was signifi-
cantly correlated with the Suicide Skills subscale, such that more
 This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

116

Table 2
Georgia Skilled Workers Performance Compared With the Average on the Suicide Knowledge Survey

Professional
Mean % No training QPR Online Para-professional counselor Physician Nurses Social worker Support staff Admin
correct (n ⫽ 832) (n ⫽ 66) (n ⫽ 609) (n ⫽ 413) (n ⫽ 235) (n ⫽ 29) (n ⫽ 129) (n ⫽ 125) (n ⫽ 212) (n ⫽ 124)

1. Few people want 62.2% ⫺.2% ⫺5.3% 1.5% 1.1% ⫺.4% 4.5% ⫺.2% 3.4% 2.4% .5%
to kill themselves (⫺.51–.11) (⫺10.75–.15) (.53–2.47) (.15–2.05) (⫺1.20–.40) (⫺2.92–11.92) (⫺.97–.57) (.26–6.54) (.34–4.46) (⫺.73–1.73)
(F)
2. Youth ages 10 to 38.6% ⫺3.3% 27% .4% ⫺2% 12.8% 21.4% ⫺1.4% 20.5% ⫺16.4% 3.5%
24 have a (⫺4.52–⫺2.08) (16.12–37.88) (⫺.10–.90) (⫺3.28–⫺.72) (8.60–17.00) (6.72–36.08) (⫺3.43–.63) (13.48–27.52) (⫺21.38–⫺11.42) (.29–.6.71)
significantly
greater risk of
suicide than
individuals ages
65 or older (F)
3. The rate of suicide 8.9% .5% 6.5% ⫺1.6% ⫺2.6% 3.5% 14.4% 2% .5% 3.2% .7%
among those with (.02–.98) (.51–12.49) (⫺2.60–⫺.60) (⫺4.06–⫺1.14) (1.18–5.82) (1.84–26.96) (⫺.42–4.42) (⫺.73–1.73) (⫺5.57–⫺.83) (⫺.76–2.16)
severe mental
illness is 6 times
the general
population (T)
4. If a person is 83.6% .1% 7.2% 1% .2% 4.1% ⫺.8% ⫺3.9% 5.5% .8% 6.2%
serious about (⫺.12–.32) (.92–13.48) (.21–1.79) (⫺.21–.61) (1.61–6.59) (⫺4.04–2.44) (⫺7.25–⫺.55) (1.55–9.45) (⫺.40–2.00) (2.01–10.39)
suicide, there is
little that can be
done to prevent it
(F)
5. If you talk to a 82.5% ⫺1.7% 4.8% 4.6% 1.1% 12.1% 14.1% 5% 11.3% ⫺7.9% 0%
consumer about (⫺2.59–⫺.81) (⫺.48–10.08) (2.93–6.27) (.14–2.06) (7.99–16.21) (1.43–26.77) (1.22–8.78) (5.82–16.78) (⫺11.56–⫺4.24) (0–0)
suicide, you may
inadvertently give
them permission
to seriously
consider it (F)
6. Depression 75.4% 2.9% 9.2% ⫺2.2% ⫺.7% 1.6% 14.6% 9% .4% ⫺4% 2.6%
indicates a suicide
SMITH, SILVA, COVINGTON, AND JOINER

(1.75–4.05) (2.17–16.23) (⫺3.37–⫺1.03) (⫺1.46–.06) (.03–3.17) (1.96–27.24) (4.04–13.96) (⫺.69–1.49) (⫺6.65–⫺1.35) (⫺.17–5.37)
risk (T)
7. Suicide is always 77.3% .2% 16.4% 1.1% ⫺1.6% 16.1% 2.7% ⫺1.3% 13.3% ⫺8.3% 3.7%
unpredictable (F) (⫺.11–.51) (7.26–25.54) (.27–1.93) (⫺2.76–⫺.44) (11.48–20.72) (⫺3.10–8.50) (⫺3.25–.65) (7.42–19.18) (⫺12.01–⫺4.59) (.40–7.00)
8. Suicidal people 80.7% 0% 6.4% 3.1% 1.9% 6.9% ⫺14% 6% 10.7% ⫺5.6% 1.8%
want to die (F) (0–0) (.31–12.49) (1.72–4.48) (.64–3.16) (3.70–10.10) (⫺26.42–⫺1.58) (1.89–10.11) (5.34–16.06) (⫺8.69–⫺2.51) (⫺.52–4.12)
9. Individuals with 32.4% ⫺1.2% 7.3% 1.5% 1.7% 4.2% 10.9% 2.5% 2.2% ⫺6.1% ⫺2.8%
BPD frequently (⫺1.95–⫺.45) (.88–13.72) (.53–2.47) (.51–2.89) (1.68–6.72) (⫺.25–22.05) (⫺.19–5.19) (⫺.35–4.75) (⫺9.31–⫺2.89) (⫺5.69–.09)
discuss or gesture
suicide but do not
really intend to
kill themselves;
instead they
intend to provoke
or manipulate
others (F)

Note. 95% confidence intervals are contained within the parentheses.

 AN ASSESSMENT OF SUICIDE-RELATED KNOWLEDGE
Table 3
Study 2 Effect Sizes (h Values) for the Pairwise Comparison of
Differences of Percentages
QPR Online No training
ⴱ
Q1 .07 .01
Q2 ⴱ
.27 .31
Q3 ⴱ
.13 ns
ⴱ
Q4 ns .11
ⴱ ⴱ
Q5 .09 (QPR), .08 (Online)
ⴱ ⴱ
Q6 .14 (QPR), .06 (No Training)
ⴱ cidal behavior is often predictable, despite the common misunder-
Q7 .23 .24
Q8 ns ⴱ
.04
ⴱ ⴱ
Q9 .09 (QPR), .03 (Online)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Note. ⴱ indicates that a group outperformed another group at a statisti-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
cally significant level; the h value presented is the measure of that effect.
Thus, for Question 1, the Online group performed significantly better than
the No Training (h ⫽ .01) and QPR groups (h ⫽ .07).
knowledge was associated with greater confidence in one’s skills,
r ⫽ .30, p ⬍ .001.
Discussion
In comparing how QPR training and Online training were re-
lated to performance on the survey, we found that those with QPR
training outperformed those with Online training and No Training
in terms of knowledge about suicidal behavior and confidence in
their skills in dealing with suicidal individuals. Those with Online
training reported greater confidence in their skills than those with
No Training. We also compared the performance of the profes-
sional groups on their suicide knowledge and found that social
workers did better than paraprofessionals, and support staff scored
significantly lower than all the other professional groups. Further,
we found that physicians, clinicians, and social workers reported
more confidence in their suicide skills than paraprofessionals and
administrators. Again, support staff reported significantly less con-
fidence in their skills than all the other groups.
As with Study 1, there was not a significant interaction between
professional group and training on suicide knowledge scores, but
there was for suicide skill scores. The nature of the interaction
was such that QPR training was associated with higher Suicide
Skills scores than Online training and No Training for administra-
tors and support staff. Online training was associated with higher
Suicide Skills scores when compared with No Training for para-
professionals and support staff.
The limitations of Study 2 are similar to those of Study 1. As
with Study 1, attendance for the online and QPR training was
self-selected, thus people who attended QPR training may have
been more interested and knowledgeable about suicide initially.
Further, the lack of experimental design restrains the study’s
conclusions. Additionally, there may not have been enough people
who received QPR training within some professions to detect
differences among the groups.
Overall these findings suggest that QPR holds potential as an
effective training program for health professionals. Further, as
seen in Study 1, support staff may be an important group to target
for training as overall they had the lowest confidence in their
skills; however, support staff who received training had higher
suicide skills scores than those who did not.
117
General Discussion
One aim of the present set of studies was to examine skilled
workers’ understanding of suicidal behavior. Overall, respondents
were well attuned to some common misunderstandings about
suicidal behavior but not others. For example, the majority of
respondents (82–93%) demonstrated that they knew that an en-
trenched myth, “Talking about suicide may inadvertently give the
person permission to seriously consider it,” is just that—a myth.
Moreover, approximately 80% of participants understood that sui-
standing that many suicides are enacted “on a whim.” However,
about half of the respondents incorrectly answered questions per-
taining to suicide rates. Specifically, many participants did not
know that adults 65 and older are at a greater risk for suicide than
adolescents and young adults. Over two thirds of participants were
not aware of the extremely high rate of suicide in people with
severe mental illness compared to the general population, and
more than half of respondents endorsed a common misperception
that individuals with Borderline Personality Disorder (BPD) fre-
quently gesture but do not really intend to kill themselves.
An additional aim of this study was to evaluate various types of
gatekeeper training. Both ASIST and QPR training were associ-
ated with higher suicide-related knowledge and confidence in
participants’ training, skills, and support. Across the two studies,
physicians and clinicians tended to score the highest on the ques-
tions pertaining to both skills and knowledge. Similarly, Reis and
Cornell (2008) found that among school personnel who had un-
dergone QPR training, counselors outperformed teachers. Given
this, it may be important to capitalize on medical and clinical
leadership in designing and implementing training programs. Fur-
ther, although there was not a significant interaction between
professional group and training type on suicide knowledge,
ASIST, QPR, and Online training was associated with higher
confidence in skills for certain groups, such as case managers.
Given that many health professionals report significant fears and
anxieties regarding working with suicidal individuals (Pope &
Tabachnick, 1993), feeling confident in one’s skills could be
important in increasing case managers’ engagement with suicidal
clients. Further, the theory of planned behavior (Ajzen, 1985)
suggests that, just as behavioral, normative, and control beliefs
formulate intention and behaviors, factors that may change these
beliefs (e.g., knowledge and confidence) may also result in
changes in behaviors (e.g., increase suicide assessment and referral
among staff).
It is important to note, however, that the uncontrolled nature of
these studies limits the causal conclusions that can be drawn
regarding the link between higher knowledge and confidence and
ASIST and QPR training, especially among specific occupations.
Indeed, greater knowledge or confidence associated with gate-
keeper training may be the result of a self-selection bias or directly
related to the functions of and exposure to suicidal clients of
certain occupations. Future research may clarify this question by
randomly assigning health care workers to different types of gate-
keeper training versus none at all, while assessing for previous
training, baseline knowledge and confidence, as well as occupa-
tional experience with and exposure to suicidal clients.
It is also important to consider the reported effect sizes when
interpreting the results. When interpreting small effect sizes it can
 118 SMITH, SILVA, COVINGTON, AND JOINER
be helpful to consider the effect sizes found in similar studies.
However, it is difficult to compare the effect sizes from the current
studies to other studies that have examined the association between
gatekeeper training and participants’ knowledge and skills about
suicide, as many of these studies have not reported effect sizes
(e.g., Capp, Deane, & Lambert, 2001; King & Smith, 2000; Stuart,
Waaler, & Haelstromm, 2003; Tompkins, Witt, & Abraibesh,
2010). However, at least one study found small to medium sized
effects for improvements in clinicians’ knowledge and self-
efficacy after receiving gatekeeper training for a veteran popula-
tion (Matthieu, Cross, Batres, Flora, & Knox, 2008). Additionally,
when interpreting the results it is important to note the large
sample sizes used across both studies. Nevertheless, the small
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
effects found in these studies may have important public health
This document is copyrighted by the American Psychological Association or one of its allied publishers.
implications, in particular for a devastating outcome like suicide.
When it comes to death by suicide, if it could be shown that
making relatively inexpensive changes, like implementing gate-
keeper training, would increase suicide prevention even by a small
amount, this could be a significant improvement, particularly if the
training was applied to all health care workers, and even more so
if the effect were additive over time.
The studies possess several notable strengths. First, they address
an understudied issue with substantial public health significance—
the preparation of our professional workforce to assess and treat
suicidal individuals. Second, these studies included large commu-
nity samples of health workers. Third, among studies of gatekeeper
training, the majority of studies has focused on health care workers
in school and university settings; this study adds to the literature by
reporting on gatekeeper training among a broad array of health
care professionals from various parts of the United States.
It appears that overall skilled workers are knowledgeable about
suicidal behavior, but that there are some specific gaps in their
knowledge, such as the rates of suicide in special populations. It
may be useful for training programs to include a section on at risk
populations, which include the elderly, the seriously mentally ill,
and those with Borderline Personality Disorder. Further, it may be
helpful for CEOs of community behavioral health care providers to
assess staff regularly on general knowledge and confidence with
regard to suicide, and to make available various training resources
to employees who feel lacking in confidence. Aside from formal
training, agency leaders could provide staff with access to current
research on suicide risk factors, structured suicide assessments,
and prevention strategies. Similarly, it could be useful for com-
pany leaders to provide staff with clear protocols, based on re-
search, for dealing with imminent suicide risk. Additionally, easily
accessible resources could be provided to at risk clients (e.g., list
of therapists, intervention programs in the community specifically
geared toward suicidal clients in the community, hotlines). Imple-
mentation of these suggestions would help to further answer the
Surgeon General’s call to action to prevent suicide by broadening
awareness of suicide and its risk factors.
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Received February 4, 2012
Revision received July 30, 2012
Accepted August 7, 2012 䡲

Call for Submissions: Psychological Science in MedEdPORTAL Publications

In recognition of the importance of psychology as both a basic and clinical science in the preparation
of the health care workforce, Barney Beins, PhD (Associate Editor, MedEdPORTAL) is now
soliciting submissions related to psychological science as part of a collaboration between the
American Psychological Association and the Association of American Medical Colleges to create an
online-only collection of free, peer-reviewed educational resources in MedEdPORTAL Publications.
This repository is used across the health professions in the preparation of future practitioners.

Accepted submissions are complete stand-alone learning or teaching modules that have been
successfully implemented in the classroom or clinical training environment. This effort is to collect
case studies of pedagogical approaches to promote the scholarship of teaching and learning. See the
MedEdPORTAL Publications site (https://www.mededportal.org/) for current examples and in-
structions for submission. We especially encourage submission of resources that facilitate the
teaching of foundational psychological science related to behavior and health. Sample topics are
listed below, but submissions are not limited to these areas.

● Social, emotional, and cognitive development ● Violence

● Memory ● Psychometrics
● Perception ● Stress and coping
● Psychophysiology ● Treatment adherence
● Psychoneuroimmunology ● Grief
● Interpersonal relationships ● Behavioral health risk factors
● Behavior change ● Obesity and weight management
● Motivation ● Smoking cessation
● Decision making ● Mental and behavioral disorders
● Leadership ● Health belief models
● Unconscious bias ● Dental anxiety
● Group dynamics and team ● Pain
functioning ● Provider–patient communication