No-suicide Contract Research Articles

Suicide planning type interventions as an evidence based alternative for no-suicide contracts

Introduction Suicidality is a common concern in psychiatric patients and one of the leading causes of death in adolescents and young adults. (Adolescent health. (2019, November 26) WHO). Some mental health professionals engage in a no-suicide contract with their patients. In this type of intervention, the patient usually agrees to not harm or kill himself/herself. There is an increasing body of evidence to support brief interventions, such as group of safety planning-type interventions (SPTIs) (McCabe et al. MC Psychiatry, 2018, May 3; 18(1)). Safety planning is derived from cognitive therapy and cognitive behavioral therapy used for suicide prevention.ObjectivesOur objective was to summarize and critically analyze current evidence of effectiveness of SPTIs and no-suicide contracts in suicide prevention.MethodsWe conducted a literature review to compare no-suicide contract to safety-planning interventions in suicide prevention.ResultsAlthough no-suicide contracts may work for some individuals, there is not enough quantitative evidence to support such contracts as clinically effective tools. A recent meta-analysis has shown that SPTIs were associated with reductions in suicidal behaviors although no effect was identified with frequency of suicidal thoughts (Nuij et al. (2021, April 30). The British Journal of Psychiatry, 219 (2), 419–426).ConclusionsBased on the evidence and straightforward implementation of SPTIs in different clinical settings it may to be a more effective alternative to no-suicide contracts.Disclosure of InterestNone Declared

Clinical Practice Guidelines for Management of Suicidal Behaviour.

Clinical Practice Guidelines for Management of Suicidal Behaviour.

Suicide Intervention Practices: What Is Being Used by Mental Health Clinicians and Mental Health Allies?

Objective Implementation of evidence-based suicide prevention is critical to prevent death by suicide. Contrary to previously held beliefs, interventions including contracting for safety, no-harm contracts, and no-suicide contracts are not best practices and are considered contraindicated. Little is known about the current use of best practices and contraindicated interventions for suicide prevention in community settings. Methods Data were collected from 771 individuals enrolled in a suicide prevention training. Both mental health clinicians (n = 613) and mental health allies (e.g., teachers, first responders) (n = 158) reported which best practices (i.e., safety plan, crisis response plan) and contraindicated interventions (i.e., contracting for safety, no-harm contract, no-suicide contract) they use with individuals who presents with risk for suicide. Results The majority of both mental health clinicians (89.7%) and mental health allies (67.1%) endorsed using at least one evidence-based practice. However, of those who endorsed using evidence-based interventions, ∼40% of both mental health clinicians and allies endorsed using contraindicated interventions as well. Conclusion Contraindicated interventions are being used at high rates and suicide prevention trainings for evidence-based interventions should include a focus on de-implementation of contraindicated interventions. This study examined only a snapshot of what clinicians and allies endorsed using. Additional in depth information about each intervention and when it is used would provide helpful information and should be considered in future studies. Future research is needed to ensure only evidence-based interventions are being used to help prevent death by suicide. Highlights: The majority of both mental health clinicians and mental health allies use evidence-based practices for suicide prevention. This indicates good implementation rates of evidence-based interventions for suicide prevention. Approximately 40% of both mental health clinicians and mental health allies who endorsed using evidence-based practices for suicide preventions also endorsed using contraindicated interventions. A focus on de-implementation of contraindicated suicide interventions is warranted and should be part of the focus on suicide prevention efforts.

Safety Planning for Suicidality in Autism: Obstacles, Potential Solutions, and Future Directions.

Safety Planning for Suicidality in Autism: Obstacles, Potential Solutions, and Future Directions.

Machine Learning Algorithms in Suicide Prevention: Clinician Interpretations as Barriers to Implementation.

Machine learning algorithms in electronic medical records can classify patients by suicide risk, but no research has explored clinicians' perceptions of suicide risk flags generated by these algorithms, which may affect algorithm implementation. The objective of this study was to evaluate clinician perceptions of suicide risk flags. Participants (n = 139; 68 with complete data) were mental health clinicians recruited to complete online surveys from October 2018 to April 2019. Most participants preferred to know which features resulted in a patient receiving a suicide flag (94.12%) and reported that knowing those features would influence their treatment (88.24%). Clinicians were more likely to report that some algorithm features (increased thoughts of suicide) would alter their clinical decisions more than others (age, physical health conditions; χ² = 270.84, P < .001). Clinicians were more likely to report that they would create a safety/crisis response plan in response to a suicide risk flag compared to other interventions (χ² = 227.02, P < .001), and 21% reported that they would complete a no-suicide contract following a suicide risk flag. Clinicians overwhelmingly reported that suicide risk flags in electronic medical records would alter their clinical decision making. However, clinicians' likelihood of acting in response to a suicide risk flag was tied to which features were highlighted rather than the presence of the risk flag alone. Thus, the utility of a suicide risk algorithm will be reduced if clinical features underlying the algorithm are hidden from clinicians or if clinicians do not view the clinical features as intuitively meaningful predictors of suicide risk.

Suicidal Behaviours among Polish Youth in Light of the following Papers: Suicidal Behaviour in Children and Adolescents. Parts 1 and 2

Dear Editor: It appears from the literature reviews by Dr Margaret M Steele and Dr Tamison Doey1'2 that, both in America and in Europe, a broad definition of attempted suicide (AS) prevails, interchangeably replaced by deliberate self-harm (DSH), which is not, however, informative as to whether any suicidal intentions are associated with a self-harm action.3 Polish studies4 suggest that psychiatric patients with multiple DSH incidents without suicidal intentions differ from AS patients, for example, by personality profiles and emotional intelligence levels, what prompts an immediate assumption that differentiation between these 2 groups of patients is of therapeutic significance. Data from questionnaire enquiries, targeting more than 3000 school students in the Lodz Region (from 2002 to 2006), have demonstrated that DSH in history is really associated with high suicidal risk. Students with confirmed DSH reported suicidal thoughts (in lifespan) twice as often as those without DSH. Regarding other suicidal, risk-related factors, for example, psychiatric therapy, self-destruction acts in a closed environment, violence records, substance addiction, law violation, feeling sadness, fear or hopelessness, and a lack of impulse control should focus clinicians' attention, while prompting appropriate therapy.5 According to Polish standards (see the review),2 any teenager who has AS should be referred for psychiatric examination; this is rather difficult in practice with 1 psychiatrist per 40 000 population at a developmental age in the Lodz Region, while to European standards there is an assumption of 1 psychiatrist per 25 000 population. The second part of the report by Dr Steele and Dr Doey2 is an example of a scientific thesis combined with a practical approach. The presented knowledge on the management of suicidal patients may be a kind of guideline, especially for Polish psychiatrists. National questionnaire enquiries, addressing practising psychiatrists, have revealed that over 50% have faced at least 1 suicidal case among their patients. In that group, two-thirds of the psychiatrists evaluated their qualifications as low. Despite Poland's accession to the European Union in 2004, no suicide prevention program has been implemented at the central level. It may then be assumed that the to-date unconfirmed efficacy of hospital therapy for minors who have AS, as indicated by the authors of the report, should rather be accounted for by methodological impediments. Following the standards of the American Academy of Child and Adolescent Psychiatry,6 hospitalization is the standard response in cases of identified high suicidal risk in youth. Some controversy may arise from questioning the efficacy of the so-called no-suicide contract. According to some suicidologists, such a contract is a consequence of a long-term process of developing a strategy to suppress suicidal prompts in crisis situations, among others, by building new relations and developing new solutions. In Poland, the internationally accepted view (presented in the review1) that suicidal behaviours in children may be elevated by medications of the selective serotonin reuptake inhibitors group has reduced the number of minors medically treated for depression. Prediction of the consequences, which may emerge from such therapeutic decisions, such as their effect on the prevalence of suicidal behaviours in this population of Polish adolescents, is rather difficult owing to the lack of an AS register at the central level. …

An Examination of the Dutch Health Care Inspectorate's Supervision System for Suicides of Mental Health Care Users

An Examination of the Dutch Health Care Inspectorate's Supervision System for Suicides of Mental Health Care Users

Responses to patients with suicidal ideation among different specialties in general hospitals

Objective The purpose of this study was to examine whether there were any differences in responses to patients with suicidal ideation among specialties in general hospitals. Methods A cross-sectional questionnaire study was conducted in 2007. The subjects of the study were chief physicians at 75 emergency departments, 69 internal medicine departments and 154 psychiatry departments in 161 general hospitals with psychiatric beds in Japan. Results The physicians in internal and emergency medicine reported making arrangements for needed counseling services and recommending to patients that they talk to the people around them, whereas those in psychiatric departments reported asking patients to promise not to commit suicide (no-suicide contract) and making a next appointment for them. Conclusions Internists and emergency physicians are likely to take different approaches when responding to patients with suicidal ideation than psychiatrists.

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.

Evaluation of attempted-suicide management in a rural district of KwaZulu-Natal

&lt;p&gt;&lt;strong&gt;Objectives.&lt;/strong&gt; Critical aspects in the management of attempted-suicide patients have been identified in the literature. The aim of this study was to determine which of these aspects were included in the management of patients who attempted suicide in a rural district of KwaZulu-Natal.&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Design.&lt;/strong&gt; Descriptive study. Setting. The two hospitals in a rural district of KwaZulu-Natal.&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Subjects.&lt;/strong&gt; Attempted-suicide patients admitted to the above two hospitals between 1 June 2001 and 31 March 2002.Outcome measures. Patients were interviewed regarding how they were managed and were followed up until 3 months after the attempted suicide.&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results.&lt;/strong&gt; Medicine was given to 41% of participants on admission and 64% were counselled by a doctor. A no-suicide contract was entered into in 42% of counselled cases. Family therapy, social worker involvement and psychiatric referral were very low and there was no involvement of friends, teachers or priests.&lt;strong&gt; &lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion.&lt;/strong&gt; Management of patients who attempted suicide in this district is inadequate as there are no proper policy guidelines. It is important that health caregivers be trained in psychiatry.&lt;/p&gt;

The case against no‐suicide contracts: The commitment to treatment statement as a practice alternative

This article reviews the literature on the use of "no-suicide contracts" in clinical practice, including conceptual discussions, patient and clinician surveys, and a few empirical studies on clinical utility. Our primary conclusion is that no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness in the clinical environment. The authors provide and illustrate the commitment to treatment statement as a practice alternative to the no-suicide contract.

Suicide Prevention: Critical Elements for Managing Suicidal Clients and Counselor Liability Without the Use of a No-Suicide Contract

ABSTRACT Despite its entrenchment as a standard of practice, no-suicide contracts fail to achieve their purpose as an effective part of treatment or as an effective method of inoculating counselors against potential lawsuits should a client commit suicide. Critical elements for managing suicidal clients and counselor liability without reliance on the no-suicide contract are presented. Therapeutic considerations include evaluating clients to determine (a) no referral for hospitalization needed, (b) referral for voluntary hospitalization, or (c) referral for involuntary hospitalization.

'No-suicide contracts' and informed consent: an analysis of ethical issues.

The 'no-suicide contract' is a frequently utilized tool in both the assessment and dispersal of suicidal patients. However, little attention has been given to questioning whether suicidal persons are able to give informed consent to enter such a contract. This article utilizes both the existing literature on no-suicide contracts and the results of recent research into the effects of this tool, to examine whether its use is consistent with the legal and ethical doctrine of informed consent. Particular attention is given to issues of competence, fullness of information, voluntariness and paternalistic intervention when no-suicide contracts are used. This analysis finds the tool to be problematic and suggests that individual patients' ability to give informed consent about a no-suicide contract needs to be carefully considered by clinicians.

NO-SUICIDE CONTRACTS AMONG COLLEGE STUDENTS

This study evaluates the use of 3 no-suicide contracts that differed in length from 1 to 9 sentences, and in specificity from indicating that clients will talk to a friend or therapist to a clear outline of persons and interventions to be used if they feel suicidal. Of the sample of 112 college students, 40% admitted to suicidal ideation and 54% reported some form of previous counseling. Students read all 3 contracts and rated them on how well they helped stop suicidal thoughts, communicated that the therapist cared, strengthened resistance to suicide, lessened depression, gave hope, encouraged cooperation with therapy and empowered, and how much they were complicated, short, or unrealistic. Regardless of gender, ethnicity, history of counseling, or prior suicidal ideation, students rated the more detailed contract best overall. Although other groups may respond differently, for college students, a specific, detailed no-suicide contract is best.

The no-suicide contract: possibilities and pitfalls.

FROM THE LITERATURE The management of the suicidal patient is one of the greatest clinical challenges facing mental health professionals. The overall suicide rate in the United States is 11-12 per 100,000, and more than 90% of those who complete suicide have diagnosable psychiatric disorders at the time of their death (1). A commonly used clinical strategy for managing suicidality, the no-suicide contract, first promoted by Drye et al. in 1973, has gained widespread acceptance as a useful tool for managing the at-risk patient (2, 3). In the era of managed care, mental health clinicians' reliance on use of no-suicide contracts is increasing (4); yet, in spite of its popularity there is disagreement as to its value, an absence of empirical support and efficacy data, and a dearth of guidelines for its use (3). What follows is a review of recent literature concerning the use of no-suicide contracts, including potential benefits and pitfalls. The no-suicide contract is also referred to as the no-harm contract or suicide-prevention contract. It is an agreement in which the therapist elicits a promise from the patient that if the patient experiences suicidal ideas or impulses, the patient will inform a health care provider, family member or friend, rather than engage in self-injurious behavior (3-5). Simon offers the following as an example of a no-suicide contract: We (clinician and patient) agree that you (patient) will call me if you find that you are worrying about harming yourself. If you feel you need immediate help and cannot reach me at that moment, you will go directly to the emergency room (specifically designated.) I will then be in touch with the emergency room. If you need to be seen between appointments, I will be available to see you (4, 6). While the agreement can be written or verbal, it is essential that the terms of the agreement be overtly stated, not implied (6). The refusal by the patient to agree to a no-suicide contract does not always mean that the patient is imminently at risk for suicide nor does a patient's acceptance of such an agreement indicate a lowering of risk, as patient's reasons for agreeing to a no-suicide contract may be conflicting and multidetermined (4, 7). A patient who is committed to acting out suicidal wishes may agree to a no-suicide contract simply to attain freedom to do so, while a manipulative patient seeking refuge in a hospital may refuse to agree to one, in order to gain admission (3, 4). Unfortunately, postmortem reviews of suicides found that suicide-prevention contracts had frequently been employed, suggesting that patients who agree to no-suicide contracts continue to be at risk, and should not reduce the need for clinicians to maintain a high level of vigilance (7). In fact, a serious limitation to the use of no-suicide contracts is that they may falsely reassure the therapist and result in decreased attention and concern about a patient's suicide risk (4). A viable therapeutic alliance is the basis, and may be prerequisite, for the establishment of a no-suicide contract. In addition, the process of contract negotiation may influence the therapeutic alliance in a positive or negative manner (3, 4). The formation of the contract can facilitate the development or enhancement of a therapeutic alliance via the open expression of caring by the therapist integral to the process of contracting (5, 8, 9). If however, while contracting for safety, the clinician is viewed as more interested in practicing defensive medicine than in the patient's welfare, the therapeutic alliance may be reduced (7, 9). For some clinicians, the patient's response to a no-suicide contract is seen as a measure of the status of the therapeutic alliance. A patient's refusal to agree to a no-suicide contract may suggest that the patient is potentially unable to control his/her impulses, and/or may be an indication that the therapeutic alliance is in a compromised state (3, 4). …

IS TRAINING IN PSYCHOLOGY ASSOCIATED WITH INCREASED RESPONSIVENESS TO SUICIDALITY?

Training is associated with improved responses to suicidal individuals, but it is not clear whether any training helps or whether the training needs to be in psychology. The authors compared beginning and advanced psychology graduate students and practicing psychologists to nursing graduate students. A total of 139 participants in these 4 groups read a vignette about Pat, who had either contemplated suicide or never contemplated suicide, then completed questions about how they would respond to a distressed telephone call from Pat, how suicidal they thought Pat was, and how good a no-suicide contract would be for Pat. Advanced students and psychologists were more helpful in their responses than beginning graduate students, who were more helpful than nursing graduate students. However, all participants noticed whether Pat had contemplated suicide, and all were faintly positive about no-suicide contracts.

Use of no-suicide contracts by psychiatrists in Minnesota.

The no-suicide contract is widely recommended as an important intervention in the care of suicidal patients; however, there are no data demonstrating its effectiveness or its acceptance in the professional community. This study examines the use of no-suicide contracts by psychiatrists in Minnesota. A postcard questionnaire was mailed to 514 psychiatrists in Minnesota inquiring about their practices and experiences with no-suicide contracts. There were 267 responses, yielding a response rate of 52%. No-suicide contracts were used by 152 (57%) of the respondents. Within this group, 62 (41%) of the psychiatrists had patients who committed suicide or made serious attempts after entering into a no-suicide contract. Among the respondents to the questionnaire, slightly more than half used no-suicide contracts, indicating that such contracts are not universally accepted as standard practice among these psychiatrists. More data are needed to determine the effectiveness of no-suicide contracts in preventing suicide.

The aftercare of adolescents with deliberate self-harm.

The evaluation and aftercare of the adolescent suicide attempter is described. The assessment of suicidal risk is aimed at the identification of those factors present in the patient and environment that make repetition of suicidal behavior likely. These factors, along with the motivation and precipitant for the suicide attempt, are used to determine the intensity of care and targets of treatment. Important elements of treatment include: obtaining a no-suicide contract, addressing potential sources of noncompliance, determining proper intensity of treatment, provision of family psychoeducation addressing ongoing family difficulties, treatment of co-occurring psychopathology, and remediation of social skills and problem-solving deficits.

Adolescent suicide: assessment and intervention.

Understanding how to prevent suicide, the third leading cause of adolescent death, is the focus of this article. To prevent suicide, the nurse assesses risk factors, covert messages, overt suicide clues, and intervenes with the adolescent and family. Suicide risk and hopelessness decrease as suicidal youths learn to clarify problems, rally significant others, expand resources and use safe coping strategies. Interventions include a no-suicide contract, family therapy and school suicide prevention programs. Nurses can identify the youth at risk for suicide and, in many cases, provide the therapy that helps prevent suicide. Vignettes illustrate strategies that effectively reduce suicide risk.