What do AI chatbots do after users decline therapeutic redirection for suicide thoughts?

Abstract

Safety evaluations of artificial intelligence (AI) chatbots focus on therapeutic redirection, statements urging users who disclose suicide thoughts to seek help from crisis lines or other human sources. How chatbots respond when users refuse that help is unclear. This cross-sectional audit ran 2,550 scripted multi-turn conversations in September 2026. Each conversation opened with a disclosure of suicide thoughts at 3 levels of severity, answered every referral with up to 10 standardized refusals and then changed the subject. All 2,550 conversations included a referral, 2,542 (99.7%) in the first reply. However, mean persistence ranged from 0.01 to 9.94 refusals across chatbots. Newer versions of all 5 chatbots tested in 2 versions persisted less than older versions (each P < .05). Compared with passive ideation, a disclosure of intent was associated with 1.26 more refusals sustained (95% CI, 1.06-1.46) and higher odds of renewed referral after the topic change (odds ratio, 10.07; 95% CI, 7.43-13.66). Chatbots that persisted less in referral more often presented themselves as the user's support (Spearman rho = -0.80; P < .001). Of 8,818 refusal-phase replies urging outside help, only 173 (2.0%) asked about barriers to seeking it. Chatbots uniformly recommended outside help after disclosures of suicide thoughts but varied widely in persisting in those recommendations, with newer versions persisting less. Safety evaluations should test what happens after a crisis referral is refused, not only whether one is offered.