From the Guidelines
Suicide prevention contracts are not generally effective in preventing suicidal behaviors. These agreements, where patients promise not to harm themselves, lack substantial evidence supporting their effectiveness and may create a false sense of security for clinicians, as noted in a study published in Pediatrics in 2016 1. Research suggests they do not reliably reduce suicide attempts or completions. Instead, comprehensive suicide risk assessments, safety planning, and evidence-based treatments are recommended. Safety planning involves identifying warning signs, coping strategies, social supports, and restricting access to lethal means.
Effective approaches include cognitive behavioral therapy for suicide prevention (CBT-SP), which has been shown to be effective in reducing the risk for suicide attempts and decreasing suicidal ideation, according to a 2025 study published in the Annals of Internal Medicine 1. Other therapies, such as dialectical behavior therapy (DBT) and collaborative assessment and management of suicidality (CAMS), may also be beneficial, although the evidence is less clear. Medications like lithium, clozapine, and ketamine may help reduce suicidal ideation in specific populations.
The therapeutic alliance between patient and provider is more important than formal contracts, as it fosters trust and encourages open communication about suicidal thoughts. Mental health professionals should focus on ongoing risk assessment and implementing individualized safety measures rather than relying on no-harm contracts. A 2021 meta-analysis published in the British Journal of Psychiatry found that safety planning-type interventions can be effective in reducing suicidal behavior, although the evidence is not yet conclusive 1.
Key considerations in managing suicidal patients include:
- Removing access to lethal means, such as firearms and medications
- Providing ongoing support and follow-up care
- Encouraging open communication about suicidal thoughts and feelings
- Using evidence-based treatments, such as CBT-SP and DBT
- Fostering a strong therapeutic alliance between patient and provider.
From the Research
Effectiveness of Suicide Prevention Contracts
The effectiveness of suicide prevention contracts in preventing suicidal behaviors is a topic of ongoing debate. Some studies suggest that these contracts can be a useful tool in managing patients in suicidal crisis, while others argue that there is a lack of quantitative evidence to support their effectiveness.
- A study published in 2020 2 describes the use of suicide prevention contracts in outpatient psychotherapy care and discusses their presumed positive effects, but does not provide quantitative evidence to support their effectiveness.
- In contrast, a study published in 2008 3 argues that there is a lack of quantitative evidence to support the use of no-suicide contracts and highlights important ethical and conceptual issues in their use.
- Another study published in 2023 4 found that suicide safety planning interventions, which involve developing a collaborative plan between a service provider and a person at risk of suicide, can be effective in reducing suicide behavior and ideation.
- A study published in 2009 5 found that empirically based evidence to support the use of contracts for safety is very limited, particularly in adolescent populations, and that contracts should be used with caution.
- A study published in 2002 6 provides an overview of no-suicide contracts and recommends that they be used in a specific, individualized, collaborative, and context-sensitive manner, but notes that they are not a substitute for sound clinical judgment.
Limitations and Controversies
The use of suicide prevention contracts is not without controversy, with some arguing that they can be coercive or introduce false security in clinicians.
- The study published in 2008 3 highlights the potential for coercion from clinicians and the ethical implications of restricting a service user's choices.
- The study published in 2009 5 notes that contracts should never replace a thorough assessment of a patient's suicide risk factors and that further empirical research is needed to determine whether contracting for safety merits consideration as a future component of suicide risk assessment.
- The study published in 2002 6 notes that no-suicide contracts are not a guarantee against legal liability and should not be used as a substitute for a caring, sensitive therapeutic interaction.