Trust in the Healthcare System Is Crucial for Patients in Suicidal Crisis
Although suicide prevention is one of the most critical responsibilities of psychiatric care, patients experiencing suicidal thoughts risk falling through the cracks. Many do not receive the support they need—either because they are considered too well for more intensive interventions or too unwell to actively participate in decisions about their care, according to a doctoral thesis from the University of Gothenburg.
Malin Rex, specialist nurse and PhD candidate, has explored how healthcare services respond to patients with suicidal thoughts. Her research shows that many patients feel they don’t fit into the system and therefore delay seeking help—often until they are in acute crisis. Once they do seek care, they risk being deemed either too mildly ill to be admitted or too severely affected to participate in decision-making. As a result, many patients are left without the support they actually need.
To improve safety for this vulnerable group, Rex argues that care systems must change—most importantly by involving both patients and their families in suicide prevention planning from an early stage.
Low trust may lead to serious consequences
As a quality developer in adult psychiatry, Malin Rex has investigated numerous incidents related to suicide. In her research, she identifies a critical gap in healthcare: patients’ trust in the system is not measured in the same way as outcomes such as time or cost. This makes it effectively invisible, despite the fact that trust can be the deciding factor in whether someone seeks help in time.
The thesis shows that many people seek help late. They try to cope on their own for as long as possible, adapting to what the healthcare system offers. When they finally do reach out, the suicidal process may already be advanced—some are so ill that they no longer wish to receive help, which makes it very difficult to meet their needs
"The thesis shows that many people seek help late. They try to cope on their own for as long as possible, adapting to what the healthcare system offers. When they finally do reach out, the suicidal process may already be advanced—some are so ill that they no longer wish to receive help, which makes it very difficult to meet their needs," says Malin Rex.
She emphasizes that low trust can have severe consequences:
"Patients who survive a suicide attempt may refrain from seeking help during the next crisis if they lack confidence in the healthcare system."
Another problem raised in the thesis is the lack of follow-up after discharge. Research shows that the period immediately after an inpatient stay is particularly critical, yet many patients are left without support during this phase. For those without family or a strong social network, an already fragile situation becomes even more difficult to manage.
Support over time – not just in crisis
Malin Rex believes that care systems must shift focus from acute and inpatient care to outpatient support.
"Suicide prevention has become so closely associated with emergency care that we, as healthcare professionals, often miss what patients actually experience. Being suicidal involves much more than the final hours or days leading up to an act. Many live for years with death as a constant possibility—intertwined with a hope to keep living."
She also highlights the need for a long-term approach:
"I believe we need to shift the emphasis from acute and inpatient care to outpatient services. That’s where stable relationships can be built and long-term work is possible. It’s also where patients, professionals, and families can together discuss what the best plan of action might be," concludes Malin Rex.
Patient safety and person-centeredness in healthcare for patients with suicidal behavior
Findings from four studies show that:
- Suicidality is often a long-term and fluctuating condition, requiring flexible and sustained care.
- Adverse events often stem from systemic issues rather than individual mistakes.
- Patients with a history of suicide attempts have different care patterns and needs compared to those without such a history.
- Both patients and relatives wish to be involved in care but are rarely given the opportunity. Patients are often seen as either too well or too ill to be included in planning and decision-making.
- There is a need for care models that combine proactive safety measures with long-term support and increased patient involvement.
