Suicide rates in the US have risen a quarter since 1999, killing nearly 45,000 Americans each year. About 90% of those who attempt or die from suicide had a diagnosable mental disorder, yet most states don’t require suicide-related training for mental health-care providers.

A new case study from Colorado, which has one of the highest suicide rates in the country, found that many providers don’t think they’re fully prepared to deal with suicide prevention and would support requirements for training. The findings were published in the Journal of Public Health Policy.

“Mental health-care providers are the frontline in suicide response; if a teacher or friend thinks someone is experiencing suicidal thoughts, they’re going to send them to a mental health-care provider,” said Laura Schwab Reese, an assistant professor of health and kinesiology at Purdue University who led the study. “Whether there’s a mandate for ongoing training or graduate education is requiring some classwork in suicide risk assessment and management, we want mental health-care providers to be ready.”

Before focusing on Colorado, the researchers considered every state’s requirements for suicide-related training for therapists, social workers, and psychologists, which make up the vast majority of the mental health workforce. At the time of the study, only Washington, Kentucky, New Hampshire, Nevada, and Utah required some form of suicide-related training for their mental health-care providers.

In a survey of more than 2,000 providers in Colorado, only 40% reported participating in suicide prevention training at least twice in the past 5 years, while 25% had no such training. Half of those surveyed had had a client attempt suicide, and more than one-third had a client who died by suicide, illustrating the necessity of suicide-related training for mental health professionals today.

“Much of Colorado is designated as having a mental health provider shortage,” Schwab Reese said. “If many of the providers there can’t address suicide, it’s really difficult to find someone else.”

More than 80% of survey responders supported requiring mental health practitioners to have some form of suicide-related education after graduate school. However, many said finding adequate training can be difficult, as much of the existing education on suicide is geared toward a lay audience.

Many respondents said that post-graduate training would be the best way to prepare providers, as graduate coursework would need substantial changes to address the education gap and it wouldn’t reach providers already practicing.

“We need to take a look at how mental health-care providers in each state are trained,” Schwab Reese said. “At the time we did the research, Indiana also didn’t require suicide-related training, which means there isn’t a systematic requirement for providers in Indiana to be trained in suicide prevention or response.”