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Reducing Suicide: A National Imperative
Suicide prevention contracts are widely used in all mental health settings as risk management tools, but they remain poorly evidenced. Also known as contracts for safety or no-suicide contracts, suicide prevention contracts ask the patient to make a commitment either verbally or in writing to avoid self-destructive behavior and to keep the clinician informed of any such suicidal impulses. However, there is no standardization in the form or content of the contract, nor in indications for use. Generally, no-suicide contracts are used in cases of acute suicidal thoughts, impulses, and behaviors, although chronic self-destructive behavior may also prompt the clinician to propose a contract.
There is scant evidence to support the efficacy of this widely used intervention, simply because so little evaluation has been done. One retrospective medical record study found that suicide prevention contracts did not prevent self-harm behaviors (Drew, 2001). Still, surveys of clinicians have found that suicide prevention contracts are commonly used, and that there is a general perception that they are helpful (Davidson et al., 1995; Green and Grindel, 1996).
A reason for the large variability in suicide prevention contracts as seen in practice is that they are not part of the formal, written tradition of suicide assessment. More often their use is perpetuated by word of mouth. A survey of psychiatrists and psychologists at Harvard Medical School points to the lack of formal training in the use of no-suicide contracts. Whereas 86 percent of the psychiatrists surveyed and 71 percent of the psychologists surveyed worked in places where contracts were regularly used, only 30–40 percent had received formal training or education during internship or residency concerning their use (Miller et al., 1998). This is just one element of the larger-scale problem in clinician training for treating suicidal patients, as discussed in Chapter 9. These data and other anecdotal accounts indicate that no-suicide contracts are a widely used intervention, but the precise prevalence rates of use are not known.
No-suicide contracts should never be used in place of appropriate suicide risk assessment and treatment (Miller, 1999; Simon, 1999). Refusal to sign a no-suicide contract does not necessarily indicate that the patient is in imminent danger of suicide, just as agreement to a contract does not mean that the risk of suicide and self-destructive behavior is lessened. The mental state of a patient is not static, and patients may have inconsistent and complex motivations for agreeing to or refusing a contract (Simon, 1999). A risk of using no-suicide contracts is that they may provide a false sense of security to the clinician and cause lessened diligence about the danger of suicide (Simon, 1999).