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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Depression, psychosis and suicide risk in later life

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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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.

Synopsis

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.

  • 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.
  • 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.

    • Key red flags

    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.

    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.

    Investigation priorities

    01
    Direct suicide enquiryFirst step

    Identify thoughts, intent, plans, preparation, access to means, past acts, ambivalence and protective factors.

    Management branches

    Immediate dangerProtect life and assess medically

    Suicidal intent, lethal preparation, severe self-neglect, command psychosis, catatonia or acute behavioural change creates urgent concern.

    1. Stay with the person when necessary, restrict means safely and contact urgent mental-health or emergency services without delaying physiological assessment.
    2. Assess delirium, intoxication, injury, intake, cognition, psychosis, capacity and safeguarding and obtain relevant collateral information.
    3. Agree or determine the least-restrictive safe setting and document formulation, information sharing, treatment and active follow-up.
    Open full textbook →Answer 2 questions
    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.
    • NICE CG178 psychosis recommendationsComprehensive psychosis assessment, physical health, treatment and monitoring principles for adults.
    • NICE CG103 delirium recommendationsRecognition of acute fluctuating cognition, perception and behaviour caused by physiological disturbance.
    • NHS urgent mental-health helpCurrent UK routes for urgent mental-health support and emergency action when life is at immediate risk.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom