Preventing Suicide among Psychiatric Inpatients with Psychotic Depression


To investigate which factors individuals with a psychotic depression experience as preventive of suicide while beeing hospitalized. Semi-structured qualitative interviews with nine inpatients, all hospitalized for a unipolar or bipolar depressive episode with psychosis, were conducted at time of discharge. For analysis we used systematic text condensation. Main outcomes were accounts of participants’ experiences of suicide prevention measures and treatment, and how these affected suicidal ideation, plans, and attempts. Participants experienced (1) suicide attempts being physically interrupted or prevented; (2) receiving medical treatment to alleviate unbearable suffering; (3) finding refuge behind locked doors; (4) receiving guidance to redefine their identity and situation. They reported being protected from suicidal impulses and imagined persecutors in a secure environment with staff present. They described their autonomy as compromised by intense suffering and chaos. They retrospectively appreciated staff interventions, if these were performed compassionately and with empathy. Participants described that suicidal thoughts and actions were triggered by terrifying psychotic experiences, anxiety and sleeplessness, and felt that medication – and in one instance electroconvulsive therapy– alleviated suffering. At time of discharge, participants reported no psychotically motivated suicidal thoughts. They described a new, insightful self-view and acknowledged having been severely mentally ill. To prevent impulsive suicidal behavior, findings highlight the need for both security measures and a treatment approach focusing on modifying psychotic experiences and intense anxiety. Gaining anxious and paranoid patients’ trust is essential to build motivation for medical treatment. Patients emphasize that having time to talk is crucial to this process.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 99

This is the net price. Taxes to be calculated in checkout.


  1. 1.

    Walsh G, Sara G, Ryan CJ, Large M. Meta-analysis of suicide rates among psychiatric in-patients. Acta Psychiatr Scand. 2015;131(3):174–84.

  2. 2.

    Mellesdal L, Mehlum L, Wentzel-Larsen T, Kroken R, Jorgensen HA. Suicide risk and acute psychiatric readmissions: a prospective cohort study. Psychiatr Serv. 2010;61(1):25–31.

  3. 3.

    Madsen T, Erlangsen A, Nordentoft M. Risk estimates and risk factors related to psychiatric inpatient suicide-an overview. Int J Environ Res Public Health. 2017;14(3).

  4. 4.

    Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatry. 1997;170(3):205–28.

  5. 5.

    Leadholm AK, Rothschild AJ, Nielsen J, Bech P, Ostergaard SD. Risk factors for suicide among 34,671 patients with psychotic and non-psychotic severe depression. J Affect Disord. 2014;156:119–25.

  6. 6.

    Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62(4):427–32.

  7. 7.

    Hawton K, Casañas I, Comabella C, Haw C, Saunders K. Risk factors for suicide in individuals with depression: a systematic review. J Affect Disord. 2013;147(1):17–28.

  8. 8.

    Kessing LV. Severity of depressive episodes according to ICD-10: prediction of risk of relapse and suicide. Br J Psychiatry. 2004;184(2):153–6.

  9. 9.

    Aaltonen KI, Isometsa E, Sund R, Pirkola S. Risk factors for suicide in depression in Finland: first-hospitalized patients followed up to 24 years. Acta Psychiatr Scand. 2018.

  10. 10.

    Caldieraro MA, Sylvia LG, Dufour S, Walsh S, Janos J, Rabideau DJ, et al. Clinical correlates of acute bipolar depressive episode with psychosis. J Affect Disord. 2017;217:29–33.

  11. 11.

    Gournellis R, Tournikioti K, Touloumi G, Thomadakis C, Michalopoulou PG, Michopoulos I, et al. Psychotic (delusional) depression and completed suicide: a systematic review and meta-analysis. Ann General Psychiatry. 2018;17(1):39.

  12. 12.

    Zalpuri I, Rothschild AJ. Does psychosis increase the risk of suicide in patients with major depression? A systematic review. J Affect Disord. 2016;198:23–31.

  13. 13.

    Heslin M, Young AH. Psychotic major depression: challenges in clinical practice and research. Br J Psychiatry. 2018;212(3):131–3.

  14. 14.

    Rothschild AJ. Challenges in the treatment of depression with psychotic features. Biol Psychiatry. 2003;53(8):680–90.

  15. 15.

    Fountoulakis KN, Yatham L, Grunze H, Vieta E, Young A, Blier P, et al. The International College of Neuro-Psychopharmacology (CINP) treatment guidelines for bipolar disorder in adults (CINP-BD-2017), part 2: review, grading of the evidence, and a precise algorithm. Int J Neuropsychopharmacol. 2017;20(2):121–79.

  16. 16.

    Leadholm AK, Rothschild AJ, Nolen WA, Bech P, Munk-Jorgensen P, Ostergaard SD. The treatment of psychotic depression: is there consensus among guidelines and psychiatrists? J Affect Disord. 2013;145(2):214–20.

  17. 17.

    Berg SH, Rortveit K, Aase K. Suicidal patients' experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies. BMC Health Serv Res. 2017;17(1):73.

  18. 18.

    Kvale S. Interviews: an Introduction to qualitative research interviewing. Thousand Oaks: SAGE; 1996.

  19. 19.

    Fredriksen KJ, Schoeyen HK, Johannessen JO, Walby FA, Davidson L, Schaufel MA. Psychotic depression and suicidal behavior. Psychiatry. 2017;80(1):17–29.

  20. 20.

    American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: DSMIVTR ®. Washington, DC: American PsychiatricPub.

  21. 21.

    First M, Spitzer R, Gibbon M, Williams J. Structured clinical interview for DSM-IV Axis I disorders, patient edition (SCID-P). New York: New York State Psychiatric Institute, Biometrics Research Department; 1996.

  22. 22.

    Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261–76.

  23. 23.

    Weibell MA, Joa I, Bramness J, Johannessen JO, McGorry PD, Ten Velden Hegelstad W, et al. Treated incidence and baseline characteristics of substance induced psychosis in a Norwegian catchment area. BMC Psychiatry. 2013;13:319.

  24. 24.

    Malterud K. Systematic text condensation: a strategy for qualitative analysis. Scand J Public Health. 2012;40(8):795–805.

  25. 25.

    Freeman D, Garety PA, Kuipers E, Fowler D, Bebbington PE, Dunn G. Acting on persecutory delusions: the importance of safety seeking. Behav Res Ther. 2007;45(1):89–99.

  26. 26.

    Huber CG, Schneeberger AR, Kowalinski E, Frohlich D, von Felten S, Walter M, et al. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry. 2016;3(9):842–9.

  27. 27.

    van der Merwe M, Bowers L, Jones J, Simpson A, Haglund K. Locked doors in acute inpatient psychiatry: a literature review. J Psychiatr Ment Health Nurs. 2009;16(3):293–9.

  28. 28.

    Rise MB, Westerlund H, Bjorgen D, Steinsbekk A. Safely cared for or empowered in mental health care? Yes, please. Int J Soc Psychiatry. 2014;60(2):134–8.

  29. 29.

    Bernert RA, Kim JS, Iwata NG, Perlis ML. Sleep disturbances as an evidence-based suicide risk factor. Curr Psychiatry Rep. 2015;17(3):554.

  30. 30.

    Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and suicidal thoughts and behaviors. J Clin Psychiatry. 2012;73(9):e1160–7.

  31. 31.

    DiazGranados N, Ibrahim L, Brutsche N, Ameli R, Henter ID, Luckenbaugh DA, et al. Rapid resolution of suicidal ideation after a single infusion of an NMDA antagonist in patients with treatment-resistant major depressive disorder. J Clin Psychiatry. 2010;71(12):1605–11.

  32. 32.

    Rothschild AJ, Winer J, Flint AJ, Mulsant BH, Whyte EM, Heo M, et al. Missed diagnosis of psychotic depression at 4 academic medical centers. J Clin Psychiatry. 2008;69(8):1293–6.

  33. 33.

    Malterud, K., Siersma, V. D., & Guassora, A. D. (2015). Sample Size in Qualitative Interview Studies: Guided by Information Power. Qualitative Health Research, Vol. 26(13), 1753–1760.

Download references


Funding organization: Stavanger University Hospital.

Author information

Kristin J. Fredriksen, Margrethe A. Schaufel, Jan O. Johannessen, Fredrik A. Walby and Helle K. Schoeyen contributed to the study conception and design. Material preparation, data collection and initial coding was performed by Kristin Joerstad Fredriksen, Helle Kristine Schoeyen and Margrethe Aase Schaufel. Data analysis was a collaboration within the group and all authors took part. The first draft of the manuscript was written by Kristin Joerstad Fredriksen and all authors commented on previous versions of the manuscript. All authors critically reviewed the paper and approved the final manuscript.

Correspondence to Kristin J. Fredriksen.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Regional Committee for Medical Research Ethics, West Norway (approval no 2012/740) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Written informed consent was obtained from all participants, who were informed that they could withdraw from the study at any point without consequence.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Fredriksen, K.J., Schaufel, M.A., Johannessen, J.O. et al. Preventing Suicide among Psychiatric Inpatients with Psychotic Depression. Psychiatr Q (2019) doi:10.1007/s11126-019-09677-6

Download citation


  • Psychotic depression
  • Suicide prevention strategies
  • Inpatient treatment
  • Patient experiences
  • Qualitative research