Do 'no-suicide' contracts work?

Suicide is the main cause of premature death in mental health service users, and the prevention of suicide is a major, global concern. An intervention designed to address this concern is the 'no-suicide' contract (NSC) - an agreement, usually written, between a mental health service user and clinician, whereby the service user pledges not to harm himself or herself. Following a review of the literature on NSCs, this paper argues that there is a lack of quantitative evidence to support such contracts as clinically effective tools and that there is strong opposition to the tool, from both service users and nurses. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection and the ethical implications of restricting a service user's choices when they may be already struggling for control. In light of these findings, the paper discusses alternative interventions aimed at preventing self-harm and suicide. Although a number of other interventions are available to clinicians, further research is required to test the effectiveness of these as viable alternatives to the NSC. © 2008 The Authors.