Psychotic disorders and suicide – Insights from medical record review in Stockholm County

Long-term psychotic disorders are among the three clinical groups with the highest risk of suicide. Approximately 10–15 percent of individuals with psychotic disorders take their own lives. Specialized psychosis care during the 1990s and 2000s in Sweden included specific proven psychosocial support interventions for patients. Today, specialized psychosis care is less common. Psychosis patients are often followed up within general psychiatric care, both in outpatient and inpatient settings.

In 2015, 230 people died by suicide in Stockholm County. Of these, 17 individuals had a psychosis diagnosis at the time of death. In a partial report, the National centre for suicide research and prevention (NASP) at Region Stockholm and Karolinska Institutet compiled healthcare contacts, care content, and psychosocial stressors for these individuals. The partial report and the medical record review study in Stockholm County is part of a larger national study.

Extensive contact with healthcare the year before suicide

The partial report shows that all individuals with psychotic disorders who died by suicide had extensive contact with healthcare services the year before their deaths. A majority of psychosis patients had also been assessed with an increased risk of suicide in the months leading up to their deaths.

Expressed psychosocial stressors close to suicide

The medical record review also reveals that individuals often openly expressed their difficulties in contact with psychiatric care. In all cases, there were notes about current psychosocial problems, such as financial hardship or relationship difficulties, at least one healthcare visit shortly before the suicide.

"It is evident that healthcare had information about the individuals' stressful life situations", says Anne Stefenson, psychiatrist, psychotherapist, and affiliated to research at NASP. "However, notes on psychosocial interventions and measures are lacking in most cases, which we have interpreted as such interventions not being carried out."

"Medical record data can be considered partially deficient in terms of notes on measures, but they still provide significant guidance", continues Anne Stefenson.

The results align with the Swedish National Board of Health and Welfare's evaluation from 2022, which shows that only a minority of patients with psychotic disorders receive the psychosocial support interventions recommended in the national guidelines for care in schizophrenia.

The partial report raises questions about how healthcare can improve its adherence to guidelines and better identify the need for support for individuals with psychotic disorders – especially in situations where the risk of suicide is increased. There is a risk that reduced specialized psychosis care, in both outpatient and inpatient settings, leads to a loss of knowledge about specific approaches and treatment options.

Medical record review study in Stockholm County

During the years 2020–2022, medical records in the IT journal system Take Care from psychiatry, primary care, and somatic specialist care were reviewed for the 230 individuals who, according to the Cause of Death Register, died by confirmed suicide in 2015 in Stockholm County. The project group also includes Linda Karlsson, doctoral student and affiliated to research at NASP, Inga-Lill Ramberg, MD, and affiliated to research at NASP, and Eva Wasserman, affiliated to research at NASP.

Publication

Stefenson, A., Karlsson, L., Ramberg, I-L., Wasserman E., Journalgranskningsstudie – Självmord i Stockholms län 2015 Delrapport 3: Personer med psykosdiagnos. Stockholm: Nationellt centrum för suicidforskning och prevention. Karolinska Institutet och Region Stockholm; 2025. Rapport 2025:04