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

No-Suicide Contracts Are Not Recommended for Suicide Prevention

No-suicide contracts (NSCs) are not recommended as a primary intervention for suicide prevention as they lack empirical evidence supporting their effectiveness and may potentially be harmful to patients. 1

Problems with No-Suicide Contracts

No-suicide contracts present several significant concerns:

• They lack empirical evidence supporting their efficacy 1
• May decrease patient communication of stress and dysphoria 1
• Can hinder the development of therapeutic alliance 1
• May introduce coercion into therapy, encouraging deceit and defiance 1
• Can create false security for clinicians 2
• May anger or inhibit the client 2
• The American Academy of Child and Adolescent Psychiatry explicitly states that "the value of no-suicide contracts is not known" 3

More Effective Alternatives

Instead of using no-suicide contracts, consider these evidence-based approaches:

1. Safety Planning Interventions

Safety planning interventions have demonstrated effectiveness in reducing suicidal behavior with a relative risk reduction of 0.570 (95% CI 0.408–0.795, P = 0.001; NNT = 16) 1. Unlike NSCs, these interventions:

• Focus on constructing predetermined coping strategies
• Identify specific sources of support
• Help patients develop concrete action plans for crisis situations

2. Comprehensive Assessment and Intervention

• Identify specific issues or situations that might promote suicidal behavior 1
• Help the family identify potential precipitants and begin problem-solving 1
• Conduct detailed discussions with patients and families about specific triggers and coping behaviors 1

3. Environmental Safety Measures

• Remove access to firearms and lethal medications 3, 1
• Limit access to alcohol or other disinhibiting substances 3, 1
• Ensure adequate supervision and support at home 3

4. Improve Treatment Compliance

• Offer definite, closely spaced follow-up appointments 1
• Be flexible in arranging appointments during crises 1
• Contact patients who miss appointments 1
• Schedule follow-up appointments before discharge 1

Clinical Implications

While NSCs continue to be used in many clinical settings 4, research consistently shows they may be ineffective or even counterproductive 5, 6. A study of inpatient settings found that patients with no-suicide contracts actually had a significantly higher likelihood of self-harm behavior (OR = 7.43, p = .005) 6.

Clinicians should recognize that NSCs are:

• Not a substitute for thorough assessment 2
• Not a guarantee against legal liability 2
• Not a replacement for caring, sensitive therapeutic interaction 2
• Not a substitute for sound clinical judgment 2

Common Pitfalls to Avoid

1. Relying solely on contracts: No-suicide contracts may create a false sense of security for clinicians 2, 5
2. Coercive implementation: Forcing patients to sign contracts can damage therapeutic relationships 1, 2
3. Using generic contracts: If contracts are used at all, they should be specific, individualized, collaborative, positive, and context-sensitive 2
4. Relaxing vigilance: Both family and clinicians should not reduce their vigilance just because a contract has been signed 3

The evidence clearly indicates that clinicians should move away from no-suicide contracts and instead implement comprehensive safety planning interventions that have demonstrated effectiveness in reducing suicidal behavior.