No Suicide Contracts Brief Report Use

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					                                                        Brief Report

       Use of No-Suicide Contracts by Psychiatrists in Minnesota
Jerome Kroll, M.D.                                                   Results: There were 267 responses, yielding a response rate of
                                                                     52%. No-suicide contracts were used by 152 (57%) of the re-
                                                                     spondents. Within this group, 62 (41%) of the psychiatrists had
Objective: The no-suicide contract is widely recommended as
                                                                     patients who committed suicide or made serious attempts after
an important intervention in the care of suicidal patients; how-
                                                                     entering into a no-suicide contract.
ever, there are no data demonstrating its effectiveness or its ac-
ceptance in the professional community. This study examines          Conclusions: Among the respondents to the questionnaire,
the use of no-suicide contracts by psychiatrists in Minnesota.       slightly more than half used no-suicide contracts, indicating
                                                                     that such contracts are not universally accepted as standard
Method: A postcard questionnaire was mailed to 514 psychia-          practice among these psychiatrists. More data are needed to de-
trists in Minnesota inquiring about their practices and experi-      termine the effectiveness of no-suicide contracts in preventing
ences with no-suicide contracts.                                     suicide.

                                                                                              (Am J Psychiatry 2000; 157:1684–1686)

C      onfronted with the necessity of assessing a patient’s
risk of a serious suicide attempt within the next 24–48
                                                                     MEDLINE search produced few references, consisting pri-
                                                                     marily of opinions, recommendations, and cautionary
hours, the clinician is forced to make a decision that cannot        notes. In the psychiatric literature, no-suicide contracts
be based on accurate prediction (1). The known risk factors,         receive brief mention as one component within a large list
although important in the assessment process, fall short of          of recommended management strategies. The thoughtful
a mandate regarding which action to take in each situation           review by Stanford et al. (3) of the history, use, and misuse
(2). Action must be taken, however, to prevent suicide.              of no-suicide contracts pointed out that these contracts
  The no-suicide contract, in which a patient formally               have no empirically demonstrated effectiveness, that no
agrees to inform a relative or health care provider of sui-          medical-legal protection is conferred, and that no stan-
cidal intent rather than acting on the intent, is widely             dardized form or technique exists for entering into such a
recommended as an evaluative and therapeutic tool. A                 contract with a suicidal patient.

1684                                                                                         Am J Psychiatry 157:10, October 2000
                                                                                                                  BRIEF REPORTS

   The no-suicide contract is often advocated as a method            suicide contracts, 44 (29%) reported that they used such
of building a therapeutic alliance, although it may actually         contracts with all patients whom they assessed as at risk for
be efficacious only when a therapeutic alliance is already           suicide, but 108 (71%) did so only with selected patients.
in place. Attempts to pressure a suicidal patient whom one             There was an inverse relationship between the use of
barely knows into making a no-suicide contract could be              no-suicide contracts and length of time in psychiatric
interpreted by the patient as a clinical retreat into legal-         practice: 39 (76%) of the psychiatrists who had been out of
isms rather than an expression of genuine concern.                   residency 5 years or less used no-suicide contracts, com-
   Furthermore, by agreeing to such a contract, a truly sui-         pared with 34 (61%) of those who had been out of resi-
cidal patient may lull the clinician into decreasing the             dence for 6–10 years and 76 (50%) of those with 11 or more
level of safety measures, and a refusal to agree to a con-           years of psychiatric practice. A logistic regression model in
tract by a truly nonsuicidal patient might lead the clinician        which use versus nonuse of the no-suicide contract was
into instituting excessive safety measures. Despite these            the response variable and sex, number of years out of res-
problems, the no-suicide contract has gained widespread              idency (0–5 versus 6 or more years), and type of practice
acceptance as a useful transaction to initiate with a sui-           were the predictor variables indicated that number of
cidal patient, and this risk management strategy is almost           years in practice was the only significant predictor of use
obligatory. Given the absence of evidence indicating                 of no-suicide contracts (odds ratio=2.28, 95% confidence
whether it is helpful or harmful, this study examines the            interval [CI]=1.07–4.83, p=0.03).
standard of care in a psychiatric community in regard to                Sixty-two (41%) of the psychiatrists who used no-sui-
use of no-suicide contracts.                                         cide contracts reported that they had patients who had
                                                                     completed suicide or made serious attempts after enter-
Method                                                               ing into the contract. Fifty-two (25%) of the psychiatrists
   A cover letter and enclosed postcard response card listing nine   with 6 or more years of experience, compared with nine
questions were mailed to 514 psychiatrists practicing in Minne-      (18%) of the psychiatrists with 0–5 years of practice experi-
sota. The names of the psychiatrists were drawn from the mem-        ence, reported that they had a patient make a serious sui-
bership list of the Minnesota Psychiatric Society and from tele-
                                                                     cide attempt after signing a no-suicide contract. A logistic
phone directories and other sources. The postcard contained
three demographic questions and six questions regarding the use      regression that included sex, number of years out of resi-
of no-suicide contracts. Replies were anonymous. Data were ana-      dency training (0–5 years versus 6 or more years), and type
lyzed by using chi-square tests for differences in proportions of    of practice again revealed that years out of residency train-
variables as well as logistic regression models to examine the       ing was the only significant predictor of whether a psychi-
multivariate relationships among and relative importance of po-
                                                                     atrist reported having a patient make a suicide attempt af-
tential predictors of use of no-suicide contracts.
                                                                     ter signing a no-suicide contract (odds ratio=0.31, 95% CI=
                                                                     0.13–0.75, p=0.009).
                                                                       One limitation in this study is the potential sampling
   There were 267 responses to the 514 questionnaires, a             bias in that the data come only from responders. The deci-
response rate of 52%. One hundred ninety-three (72%) of              sion to maintain the anonymity of responders, based on
the respondents were men and 73 (27%) were women; one                the assumption that this would improve the percentage of
person did not indicate gender. One hundred sixty-eight              returns, precluded the possibility of a second mailing to
(63%) of the respondents had an outpatient practice only,            those who failed to return a postcard or comparing the
43 (16%) an inpatient practice only, 43 (16%) a combined             characteristics of responders with those of nonre-
inpatient and outpatient practice, and 13 (5%) did not pro-          sponders. The sex distribution of the responders, however,
vide practice information. Fifty-one (19%) of the respon-            was almost identical to that of the membership of the
dents had been out of residency for 0–5 years, 56 (21%) for          Minnesota Psychiatric Society (Yates-corrected χ2=0.003,
6–10 years, 69 (26%) for 11–20 years, and 83 (31%) for more          df=1, p=0.96). A second limitation is that we do not have
than 20 years; eight (3%) did not provide this information.          patient suicide data for psychiatrists who did not use no-
Forty-five (42%) of the 107 psychiatrists who had been out           suicide contracts.
of residency for 10 years or less, compared with 24 (16%) of
the 152 psychiatrists who had been out of residency for
more than 11 years, were women (Yates-corrected χ2 =
21.61, df=1, p<0.001; Fisher’s exact p=0.0001).                        A survey of the use of no-suicide contracts among 267
   No-suicide contracts were used by 152 (57%) of the re-            Minnesota psychiatrists revealed that they were equally
spondents. Of those who used no-suicide contracts, 94                divided between those who did and those who did not use
(62%) used verbal contracts only and 58 (38%) used written           no-suicide contracts in their clinical work. This finding in-
and verbal contracts. One hundred seventeen (77%) re-                dicates that there is no community consensus or standard
ported that they used no-suicide contracts because they              of care in regard to use of no-suicide contracts as an inter-
thought it was helpful; 35 (23%) used such contracts al-             vention with suicidal patients. Although experienced psy-
though they did not think it helpful. Of those who used no-          chiatrists used no-suicide contracts less frequently, a

Am J Psychiatry 157:10, October 2000                                                                                       1685

higher percentage of experienced psychiatrists reported
serious or completed suicide attempts in patients who                Received Jan. 11, 1999; revisions received April 26 and June 7,
                                                                   1999, and March 29, 2000; accepted April 5, 2000. From the Depart-
had entered into no-suicide contracts with them. It is most
                                                                   ment of Psychiatry, University of Minnesota Medical School. Address
likely that this finding reflects the greater number of years      reprint requests to Dr. Kroll, University of Minnesota Medical School,
at risk for having suicide attempters in one’s practice. Nev-      F282/2A West, 2450 Riverside Ave., Minneapolis, MN 55454-1495;
ertheless, the finding that 41% of the psychiatrists who  (e-mail).
                                                                     The author thanks Jennifer Carey and Mary DeWitt for logistical
used no-suicide contracts in their work with suicidal pa-
                                                                   support and Joel Hechtner, Ph.D., for statistical analyses.
tients had patients who committed suicide or made seri-
ous attempts after signing a no-suicide contract under-
scores the tenuousness of counting on the contract as an           References
effective suicide prevention tool. This finding does not im-
ply that discussing a commitment to contact the physician            1. Hirschfeld RMA, Russell JM: Assessment and treatment of sui-
                                                                        cidal patients. N Engl J Med 1997; 337:910–915
or others as an alternative to suicide may not be of thera-
                                                                     2. Mann JJ, Waternaux C, Haas GL, Malone KM: Toward a clinical
peutic value to a clinician and suicidal patient, but it is
                                                                        model of suicidal behavior in psychiatric patients. Am J Psychi-
clear that the no-suicide contract has, at best, limited effi-          atry 1999; 156:181–189
cacy in general. There is a need for a randomized clinical           3. Stanford EJ, Goetz RR, Bloom JD: The no harm contract in the
trial to determine the utility (or lack thereof) of this suicide        emergency assessment of suicidal risk. J Clin Psychiatry 1994;
management tool.                                                        55:344–348

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