Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Depression, psychosis and suicide risk in later life
Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Intent, self-neglect or acute psychosis may be immediately dangerous
Current suicidal intent, a high-lethality plan or preparation, inability to maintain food, fluid or essential treatment, severe psychotic fear or commands, stupor, catatonia, violence risk, delirium, or rapidly worsening depression requires urgent same-day mental-health and medical assessment.
Action: Stay with the person when immediate risk is present, remove access to lethal means where this can be done safely, assess ABCDE and acute medical causes, obtain collateral information without delaying care, and contact urgent mental-health or emergency services. Share proportionate information to protect life and document capacity, risks, protective factors and the agreed safety response.
Overview
Recognise later-life depression and psychosis without ageist normalisation, exclude delirium and medical or cognitive causes, assess suicide and self-neglect directly, and coordinate proportionate psychological, social, medical and specialist treatment.
Later-life depression is common but never a normal part of ageing. Presentation may centre on loss of interest, reduced initiative, anxiety, guilt, irritability, poor sleep, appetite change, psychomotor slowing, physical pain or inability to manage daily tasks rather than volunteered sadness. Ask about pleasure, hope, concentration and social withdrawal using accessible language. Bereavement, retirement, caregiving, loneliness, disability and financial strain shape the presentation but do not make a depressive disorder inevitable or untreatable.
Clarify chronology, severity and previous episodes. Bipolar disorder can recur in later life, and antidepressant exposure may reveal activation; ask about past periods of reduced need for sleep, increased energy, impulsivity and grandiosity. Review alcohol and non-prescribed drugs. Examine personal and family history, trauma, losses, culture, faith, identity and current supports. Use a validated measure to support symptom tracking if helpful, but diagnosis and treatment decisions depend on clinical assessment, function and preference.
Practice
Two practice questions
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Question 1 of 2
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PsychiatryOriginal SBA
Suicide risk scale use
An older widower presents after intentional self-poisoning, and clinicians find a further tablet stockpile while he discloses intermittent intent to die. Which approach best follows NICE self-harm guidance when planning care?
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE NG222 depression recommendationsAssessment, psychotic depression, medicine and psychological treatment, ECT, relapse and suicide-related clinical care.
NICE NG225 self-harm recommendationsPsychosocial assessment, prohibition on predictive risk scales, safety planning, information sharing and aftercare.
Suicide assessment is direct and collaborative. Ask whether life feels worth living, whether the person has thought of death, harmed themselves, formed a plan, prepared, written notes, given possessions away or gained access to means. Explore timing, intent, ambivalence, prior attempts, intoxication, pain, insomnia, agitation, psychosis, cognitive impairment and recent loss. Protective relationships and beliefs matter but do not cancel a credible plan. A calm denial cannot be accepted mechanically when behaviour or collateral evidence conflicts.
NICE advises against using risk scales or global low, medium or high stratification to predict future suicide or determine discharge and treatment. Develop a formulation linking immediate and longer-term factors, foreseeable stressors, strengths, access to means and the person's capacity to seek help. Create a safety plan with warning signs, individual coping, people and places for distraction, trusted contacts, professional crisis routes and collaboratively agreed restriction or removal of lethal means.
Self-neglect may be the dangerous expression of depression. Weight loss, dehydration, missed medicines, poor hygiene and unsafe housing can also arise from dementia, delirium, poverty, physical disability, abuse or capacitous choice. Ask what the person understands and intends. Capacity is decision- and time-specific; a depressive belief such as deserving to die may impair use or weighing of treatment information. Respect autonomy while using urgent best-interests and safeguarding processes when the legal threshold is met.
New psychosis in an older adult requires a broad medical formulation. Establish whether hallucinations or delusions began abruptly, fluctuate, follow a medicine change or accompany reduced attention. Check vision, hearing, sleep, pain, infection, endocrine or metabolic illness, Parkinsonism, focal neurology and cognition. Corticosteroids, dopaminergic medicines, anticholinergics, opioids and intoxication or withdrawal are examples of contributors. Do not diagnose primary schizophrenia solely because hallucinations are present.
Psychotic depression usually occurs within a severe depressive episode, with delusions of guilt, poverty, deserved punishment, disease or nihilism, and sometimes derogatory or command hallucinations. Assess intake, self-care, suicide, catatonia and physical compromise urgently. NICE recommends specialist mental-health referral and considering an antidepressant combined with an antipsychotic, with antidepressant alone if the person does not want antipsychotic treatment. Some antipsychotic use in psychotic depression is off-label, which should be explained. Monitor psychotic content and unusual thought patterns as treatment proceeds.
Treatment for non-psychotic depression is matched to severity, history, preference, comorbidity and access. Psychological treatments remain effective and should be adapted for hearing, vision, cognition, mobility and digital exclusion. Address pain, sleep, alcohol, loneliness, bereavement, housing and carer burden alongside depression-specific care. Social prescribing cannot substitute for indicated therapy, and medication cannot correct unsafe isolation or abuse. Include the person in choices and involve supporters with consent.
Medicine selection needs geriatric pharmacology rather than reflex undertreatment. Review renal and hepatic function, bleeding risk, hyponatraemia, falls, orthostatic hypotension, cardiac conduction, anticholinergic burden and interactions. Start at an appropriate dose, titrate deliberately and monitor adherence and adverse effects; older age alone is not a reason to leave severe depression untreated. Avoid abrupt changes and check whether apparent non-response reflects inadequate dose, duration, administration, ongoing delirium or an incorrect bipolar or cognitive formulation.
NICE says to consider electroconvulsive therapy for severe depression when a rapid response is needed, such as life-threatening refusal of food or drink, or when other treatments have been unsuccessful. Discuss anaesthetic, cognitive and medical considerations, prior response and preferences, and follow the legal framework for consent, capacity and Mental Health Act safeguards where applicable. ECT is not a punishment or a routine response to age; it is a specialist treatment whose potential speed can be clinically decisive.
Follow-up intensity should reflect current risk, treatment phase and ability to access help. Arrange active contact after self-harm, crisis, discharge, antidepressant initiation or major dose change. Review sleep, agitation, psychosis, intake, adherence, sodium or ECG when clinically indicated, falls and functional recovery. Communicate plans across primary care, mental health, acute medicine and social care. Reassess diagnosis for cognitive decline, mania, neurological signs or repeated apparent delirium.
Key points
Depression is not an expected consequence of ageing; sadness may be absent while anhedonia, anxiety, irritability, slowing, sleep change, pain and loss of function dominate.
Ask directly about suicidal thoughts, intent, plans, preparation, prior attempts, access to means, reasons for living and the person's ability to use help.
Do not use a risk scale or low, medium or high category to predict suicide, decide discharge or substitute for a collaborative psychosocial formulation.
Self-neglect, treatment refusal and apparently accidental overdose require exploration of intent, cognition, psychosis, capacity and practical barriers.
New late-life psychosis warrants assessment for delirium, dementia, sensory impairment, medicines, substances, neurological disease, mood disorder and safeguarding concerns.
Psychotic depression combines a severe depressive syndrome with mood-congruent or other delusions or hallucinations and needs specialist mental-health input.
NICE recommends considering antidepressant plus antipsychotic treatment for psychotic depression; antidepressant alone is an option when the person declines the combination, and some antipsychotic use for this indication is off-label.
Consider ECT for severe depression when a rapid response is needed, for example life-threatening refusal of food or drink, or when other treatments have been unsuccessful.
Aetiology
01
Recurrent mood disorder
Earlier depressive or bipolar vulnerability can recur with later-life biological, medical and psychosocial stressors, sometimes after long remission.
02
Loss and social adversity
Bereavement, isolation, caregiving, poverty, abuse, retirement and loss of role can precipitate depression without making it an expected response.
03
Medical and neurological illness
Pain, endocrine or metabolic disease, stroke, Parkinsonism, dementia, sensory loss and sleep disorder can cause or amplify mood and psychotic symptoms.
04
Medicines and substances
Corticosteroids, dopaminergic drugs, anticholinergics, sedatives, alcohol, intoxication and withdrawal may alter mood, perception, sleep and impulse control.
Pathophysiology
1
Mood network dysfunction
Altered limbic, frontal and reward processing contributes to anhedonia, hopelessness, threat bias, reduced motivation and impaired cognitive control.
2
Vascular and degenerative burden
Cerebrovascular and neurodegenerative changes can reduce executive reserve and interact with depression, psychosis and treatment tolerance.
3
Stress and sleep disruption
Loss, pain, inflammation and insomnia sustain arousal and neuroendocrine disturbance that worsens mood, cognition and suicidal thinking.
4
Psychotic mood congruence
Severe depressive cognition can become fixed as delusions of guilt, poverty, disease or nihilism and drive dangerous refusal or self-punishment.
Clinical features and red flags
Later-life depressive syndrome
Anhedonia, loss of hope, anxiety, slowing, guilt, sleep or appetite change and functional decline may dominate over reported sadness.
Psychotic depression
Severe mood symptoms coexist with delusions or hallucinations, often involving guilt, poverty, disease, punishment or nihilistic themes.
Suicidal preparation
Stockpiling, arranging affairs, researching methods, writing notes or rehearsing can reveal intent that a simple screening question misses.
Depressive self-neglect
Reduced intake, treatment omission and unsafe living may express hopelessness or intent but require cognitive, social and physical differentials.
Secondary late-onset psychosis
New hallucinations or beliefs with fluctuating attention, cognitive change, sensory loss, medicines or neurological signs suggest an underlying condition.
Bipolar presentation
Past or current reduced sleep need, activation, impulsivity or grandiosity changes antidepressant risk and specialist management.
Red flags requiring action
A stated wish to die, active plan, recent preparation, rehearsal, concealed stockpiles or access to a highly lethal method demands urgent formulation and safety action.
Stopping food, fluid, insulin, anticoagulation or other essential care may represent suicidal intent, depressive self-neglect, psychosis, cognitive impairment or a capacitous refusal that needs careful assessment.
Investigations
01Direct suicide enquiryFirst step
Why
Identify thoughts, intent, plans, preparation, access to means, past acts, ambivalence and protective factors.
Interpretation and limitations
Formulate in context; neither denial nor a numerical risk category independently determines safety or disposition.
02Mental-state and capacity assessment
Why
Characterise depression, psychosis, mania, cognition, insight, self-neglect and decision-specific ability.
Interpretation and limitations
Psychotic guilt, hopelessness or cognitive impairment may alter urgency and the person's use or weighing of treatment information.
03Physical and neurological examination
Why
Detect delirium physiology, parkinsonism, focal signs, frailty, injury, dehydration and medicine adverse effects.
Interpretation and limitations
Acute, focal or rapidly progressive findings require medical or neurological escalation before a primary psychiatric conclusion.
04Targeted laboratory and ECG assessment
Why
Investigate endocrine, metabolic, nutritional, infectious, organ and prescribing risks selected by presentation.
Interpretation and limitations
Results guide cause treatment and medicine safety; incidental abnormalities should not erase a sustained depressive syndrome.
05
Differential diagnosis
01
Delirium
Hours-to-days fluctuating attention and arousal with perceptual change indicates physiological brain dysfunction requiring immediate cause treatment.
02
Dementia
Progressive domain and functional decline can cause apathy, psychosis and impaired self-care and may coexist with depression.
03
Bipolar disorder
Past activation, reduced sleep need, impulsivity and episodic course changes antidepressant risk and requires specialist formulation.
04
Substance or medicine effect
Recent exposure, intoxication, withdrawal and drug interactions can reproduce depression, agitation, insomnia, confusion or distressing hallucinations.
05
Sensory and neurological disease
Visual or hearing impairment, seizure, Parkinsonian, inflammatory and structural disorders can present with unusual perceptual or behavioural symptoms.
Management
01Immediate dangerProtect life and assess medicallyFirst stepSuicidal intent, lethal preparation, severe self-neglect, command psychosis, catatonia or acute behavioural change creates urgent concern.+
1Stay with the person when necessary, restrict means safely and contact urgent mental-health or emergency services without delaying physiological assessment.
2Assess delirium, intoxication, injury, intake, cognition, psychosis, capacity and safeguarding and obtain relevant collateral information.
3Agree or determine the least-restrictive safe setting and document formulation, information sharing, treatment and active follow-up.
02New late-onset symptomsFind mood, cognitive and medical causesDepression or psychosis emerges in later life without an immediately life-threatening presentation.+
1Map mood, mania, psychosis, cognition, function, losses, substances, medicines, senses, sleep and physical or neurological symptoms.
Complications
01
Suicide and lethal self-neglect
High-intent acts, refusal of intake and omission of essential treatment can cause rapid irreversible harm or death.
02
Frailty and functional loss
Inactivity, poor nutrition, insomnia and missed treatment accelerate falls, deconditioning, admission and loss of independent living.
03
Medicine toxicity
Hyponatraemia, bleeding, orthostasis, cardiac effects, anticholinergic burden and interactions may complicate treatment in later-life multimorbidity and frailty.
04
Entrenched psychosis
Untreated delusions and hallucinations can intensify fear, social isolation, treatment refusal, carer conflict and serious safeguarding vulnerability.
05
Diagnostic overshadowing
Attributing every symptom to age, depression or dementia delays recognition of delirium, neurological disease, abuse and treatable physical illness.
Monitoring and follow-up
Ask directly about suicidal thought, intent, preparation, access to means and ability to use the safety plan at every clinically relevant change.
After medicine initiation or titration review falls, orthostasis, sodium risk, bleeding, cardiac factors, anticholinergic effects, adherence and activation.
Reassess cognition and attention when the course fluctuates, recovery is incomplete or a supporter reports progressive functional change.
Confirm that crisis contacts, transport, communication aids and supporter roles are practical rather than merely written in a plan.
Coordinate post-crisis and post-discharge contact across primary care, specialist mental health, acute medicine and social care.
Special situations
Sadness may be absent
Loss of pleasure, slowed function, anxiety and physical preoccupation can carry more diagnostic weight than a volunteered low mood.
Calm does not equal safe
A person with a resolved plan and available means may appear less distressed after deciding to act.
Refusal has several meanings
Declining food or medicine may reflect intent, psychosis, delirium, dysphagia, poverty, side effects or a capacitous value-based decision.
Late psychosis broadens diagnosis
Sensory, neurological, cognitive, medical and medicine causes become especially important when psychosis begins for the first time in older age.
Rapid response can matter
ECT may be considered when severe depression threatens life through refusal of food or drink and waiting carries substantial harm.
Common pitfalls
01
Normalising hopelessness, withdrawal or loss of pleasure as ageing, bereavement or physical illness without assessing depressive syndrome.
02
Avoiding direct suicide questions for fear of introducing the idea or accepting a one-word denial despite preparation evidence.
03
Using a numerical scale or low-risk label to predict suicide, decide discharge or replace formulation and safety planning.
04
Assuming refusal of food or essential medicine is automatically a capacitous choice or automatically evidence of incapacity.
05
Diagnosing primary psychosis before assessing delirium, dementia, sensory impairment, medicines, substances and neurological disease.
06
Using antipsychotic monotherapy as though it treats the depressive syndrome in psychotic depression.
07
Undertreating because of age while failing to adjust monitoring for falls, hyponatraemia, bleeding, cardiac and interaction risks.
08
Writing a safety plan whose contacts, transport, communication method or means-restriction steps are not usable by the person.
Jurisdiction
Older adults may be more vulnerable to hyponatraemia, bleeding, orthostatic hypotension, anticholinergic effects, QT issues, falls and medicine interactions.
Safety planning identifies warning signs, coping, supportive contacts, urgent services and means restriction; arrange active follow-up after crisis or treatment change.
New hallucinations, delusions or fluctuating attention over hours or days suggests delirium, medicine toxicity or neurological illness until assessed.
Psychotic guilt, nihilistic beliefs, command hallucinations, severe agitation, stupor or catatonic signs increase urgency and need specialist review.
Severe depression with refusal of intake, rapid physical deterioration or other life-threatening features may require a treatment capable of a rapid response.
A new focal deficit, seizure, head injury, severe headache, visual hallucinations with parkinsonism or rapid cognitive decline requires an acute or neurological pathway.
Abuse, coercion, bereavement exploitation, carer violence or neglect must not be mistaken for a psychiatric symptom or ordinary family conflict.
Link symptom onset to exposures and alter treatment safely without abrupt withdrawal of essential medicines.
06Collateral and functional assessment
Why
Clarify baseline, change, intake, adherence, finances, home safety, access to means and hidden preparation.
Interpretation and limitations
Discrepancy with self-report should prompt respectful exploration, confidentiality judgment and proportionate safety action.
2
Examine and investigate clinical contributors, treating delirium, pain, endocrine, metabolic, sensory and medication problems in parallel.
3Refer severe, psychotic, bipolar, diagnostically uncertain or high-risk presentations to specialist older-adult mental-health care.
03Recovery planCombine treatment with active safety reviewA working diagnosis and initial treatment plan are established after urgent risks have been addressed.+
1Select psychological, pharmacological, social or specialist treatment through shared decision-making and adapt access for sensory and cognitive needs.
2Create a collaborative safety plan covering warning signs, coping, supportive contacts, urgent services and access to lethal means.
3EscalationReview symptoms, psychosis, intake, function, adverse effects, adherence and risk actively, escalating non-response or deterioration.