Is a no-suicide contract (NSC) helpful in preventing suicidal behavior?

No-Suicide Contracts Are Not Recommended for Suicide Prevention

No-suicide contracts should not be used as a primary intervention for suicide prevention as they lack empirical evidence supporting their effectiveness and may potentially be harmful by creating false security, inhibiting communication, and impairing therapeutic alliance. 1

Evidence Against No-Suicide Contracts

Lack of Empirical Support

• The American Academy of Child and Adolescent Psychiatry clearly states that "there have been no empirical studies that have evaluated the efficacy of a contract" 1
• Despite their common use in clinical practice, no-suicide contracts have no evidence base supporting their effectiveness 2
• A retrospective review of medical records found that patients with no-suicide contracts actually had a significantly higher likelihood of self-harm behavior (OR = 7.43, p = .005) 3

Potential Harms

• No-suicide contracts may lessen a patient's communication of stress and dysphoria 1
• They can decrease the potential for developing a therapeutic alliance 1
• Contracts may impair risk management by creating false security for clinicians 4
• They can potentially anger or inhibit clients 4
• Contracts may introduce coercion into therapy, which can encourage deceit and defiance 1

When No-Suicide Contracts Are Especially Problematic

• When used with patients who have disturbed mental states 1
• When used coercively (e.g., "unless you promise not to attempt suicide, I will keep you in the hospital") 1
• When used as a substitute for comprehensive assessment and intervention 4
• When the patient does not understand the commitment due to developmental or cognitive limitations 1

More Effective Alternatives

Safety Planning-Type Interventions (SPTIs)

• Safety planning interventions have demonstrated effectiveness in reducing suicidal behavior (RR = 0.570,95% CI 0.408–0.795, P = 0.001; NNT = 16) 1
• Unlike no-suicide contracts, SPTIs focus on constructing predetermined coping strategies and sources of support 1

Commitment to Treatment Statements

• These focus on the therapeutic process rather than extracting a promise not to engage in suicidal behavior 2
• They emphasize collaboration and engagement in treatment rather than prohibition of behavior

Comprehensive Risk Assessment and Management

• Regular, thorough assessment of suicide risk is necessary whether or not a patient has agreed to a no-suicide contract 3
• Focus on identifying specific issues or situations that might promote further suicidal behavior 1
• Help the family identify potential precipitants and begin problem-solving 1

Best Practices for Suicide Prevention

1. Conduct detailed discussions with patients and families about specific triggers and coping behaviors 1
2. Improve treatment compliance through:
   • Offering definite, closely spaced follow-up appointments
   • Being flexible in arranging appointments during crises
   • Reminding patients about appointments
   • Contacting patients who miss appointments 1
3. Secure the environment by:
   • Removing access to firearms and lethal medications
   • Limiting access to alcohol or other disinhibiting substances 1
4. Ensure adequate support is available at home 1
5. Schedule follow-up appointments before discharge 1

Conclusion

While no-suicide contracts are commonly used in clinical practice, they should not be relied upon for suicide prevention. Instead, clinicians should focus on evidence-based approaches such as safety planning interventions, comprehensive risk assessment, and ensuring appropriate follow-up care. The therapeutic relationship and ongoing support are more valuable than a contractual agreement that lacks empirical support and may potentially harm the therapeutic alliance.