The “Suicide-Prevention Contract”: A Dangerous Myth

The “no-suicide” contract, where patients are asked to sign an agreement not to commit suicide, or in common parlance, “to contract,” has become disconcertingly commonplace. A pseudo-legal agreement, it is alien to our best practices. Increasingly, clinicians refer to the need “to contract” with patients who they fear might harm themselves. It would be wonderful if contracts truly prevented such tragedies, but there are no reliable or valid data to confirm their effectiveness. Indeed, the use of such contracts flies in the face of clinical common sense and may in fact increase danger by providing psychiatrists with a false sense of security, thus decreasing their clinical vigilance.

Where did this begin? In 1973 Drye et al., in a suicide study published in the February 1973 American Journal of Psychiatry, developed a detailed questionnaire referred to as the “no-suicide decision.” In future writings this evolved into the “no-suicide contract.” The questionnaire was not designed as a contractual agreement, but rather as a vehicle to assess suicidal risk and make vital decisions about patient management. Patients were asked a series of questions regarding self-destructive thoughts and fantasies and then asked to consider the statement: “No matter what happens, I will not kill myself accidentally or on purpose at any time.” If the patients could not fully agree, they were asked what modifications would make the statement acceptable. For example, could they accept a substitute of one hour, two weeks, and so on for the phrase “at any time”?

The investigators were enthusiastic about the use of this technique as a way of continuously monitoring, not controlling, the seriousness of a patient’s suicide risk. The questionnaire assured that the clinician was continuously and methodically exploring the patient’s thoughts and feelings and was a safeguard against any conscious or unconscious tendency for the psychiatrist to shy away from asking difficult questions. What originated as a guide to evaluation has dramatically and dangerously been transposed into a “contract” that some believe will control and/or prevent suicide.

The soon-to-be-published APA Guideline for the Management of Suicidal Behavior (see page 15) states the following about prediction: “We may know the risk factors, but knowledge of the risk factors will not permit the psychiatrist to predict when or if a specific patient will die by suicide.” And in terms of a contract, it states, “The suicide-prevention contract, or ‘no-harm contract,’ is commonly used in clinical practice but should not be considered a substitute for a careful clinical assessment. A patient’s willingness (or reluctance) to enter into a verbal or written suicide-prevention contract should not be viewed as an absolute indicator of suitability for discharge. In addition, such contracts are not recommended for use with patients who are agitated, psychotic, impulsive, or under the influence of an intoxicating substance. Furthermore, since suicide-prevention contracts are dependent upon an established physician-patient relationship, they are not recommended for use in emergency settings or with newly admitted or unknown inpatients.”

Indeed, we have a good deal of knowledge about the risk factors for suicide. Suicidal ideation is a risk factor, and a previous attempted suicide is a risk factor. The danger of self-destruction is much higher for those who are younger as well as those who are older. The presence of a psychiatric disorder, with the exception of mental retardation, has been shown to increase suicide risk as measured by standardized mortality ratios. But, we still “cannot predict when or if a specific patient will die by suicide.”

Would that a “contract” could reassure us in the face of such harsh news. The uncertainty that surrounds patients’ suicidal ideation, acute and/or chronic, is one of the most emotionally troubling aspects of our professional lives. Anxiety surrounds the possibility, and should a patient suicide, it is a heart-rending experience.

We can make contracts with builders, insurers, and car dealers, but not with patients. When entrepreneurs break a contract, the rupture stirs a multitude of negative feelings, and legal action may follow. But a broken “no-suicide” contract stirs tragic feelings for all involved. No amount of legal action can restore the patient’s life. ▪