No-suicide contracts, no-suicide agreements, and no-suicide assurances: A study of their nature, utilization, perceived effectiveness, and potential to cause harm

Background: Suicide prevention contracting (SPC) procedures are often afforded clinical practice validity in the absence of evidence attesting to their efficacy and validity. Aims: This study sought to develop a contemporary profile of SPC, identifying factors associated with utilization, perceived effectiveness, and to describe potentially detrimental factors when activating SPC. Methods: A questionnaire was mailed to a sample of mental health practitioners comprising physicians, mental health nurse practitioners, and allied health practitioners to inquire about their practices and experiences with SPC. Results: There were 420 valid responses, a response rate of 31%. Participants confirmed three types of SPC procedures in operation: (1) 355 (85%) having used verbal no-suicide assurances (NSAs); (2) 317 (76%) using verbal no-suicide agreements (NSAg); and, (3) 154 (37%) using written no-suicide contracts (NSC). The profiled procedures and their clinical application indicate that participants perceived differences in the diagnostic, therapeutic, and medico-legal utility of all three SPC procedures. Importantly, SPC procedures were shown to have a multifaceted potential for detrimental outcomes for patients and practitioners. Conclusions: Until now, SPC had represented a poorly understood and remains a questionable clinical practice intervention. Education initiatives are required that alert mental health practitioners to the dangers of SPC for patients and practitioners alike, and to present alternative interventions containing less risk.