# data[].attributes.attachment_link.title
Bringing it all together - Season 02, Episode 04

# data[].attributes.headline
 National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) UK-level report 2025, which was published on 13 February, for awareness.

# data[].attributes.subject
 National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) UK-level report 2025, which was published on 13 February, for awareness.

# data[].attributes.body
NCISH is commissioned by the UK Healthcare Quality Improvement Partnership (HQIP) (with The University of Manchester) as part of the UK National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing, and National Voices.

It is designed to help assess the quality of healthcare, and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers, and policy makers to learn from adverse events and other relevant data. The 2024 annual NCISH report covers those aged 10 and above who died by suicide between 2012-2022 across the whole of the UK.

# data[].attributes.attachment_link.readable_text
In 2012-2022, there were 3,817 suicides by patients who missed their last contact with mental health services, 22% of all patient suicides, an average of 347 deaths per year.

There were 1,998 suicides by patients who were non-adherent with drug treatment, 12% of all patient suicides, an average of 182 deaths per year. Our estimates for 2022 show an increase in the proportion of patients with missed contact but a fall in those non-adherent with medication.

Missed contact was often accompanied by clinical morbidity (e.g. additional psychiatric diagnoses, self-harm, alcohol and/or drug misuse), and socioeconomic adversity (e.g. unemployment, financial problems, living alone). Services had made contact with the patient's family in 28% of those who had missed their last appointment.

The majority (63%) of non-adherent patients had severe mental illness. Half (47%) were prescribed oral antipsychotics. Reasons for non-adherence were reported to be:

the patient's impaired insight into their illness (31%);

side effects (15%);

lack of effectiveness (13%).

# data[].attributes.attachment_link.description
In 2012-2022, there were 3,817 suicides by patients who missed their last contact with mental health services, 22% of all patient suicides, an average of 347 deaths per year. There were 1,998 suicides by patients who were non-adherent with drug treatment, 12% of all patient suicides, an average of 182 deaths per year.

# data[].attributes.headline
Mental health and suicide prevention learning provision in Scotland

# data[].attributes.subject
Mental health and suicide prevention learning provision in Scotland

# data[].attributes.body
Type

Report

Published

08 October 2024

# data[].attributes.attachment_link.description
The Scottish Government’s Action Plan to address student mental health, through effective collaborative working across colleges, universities, NHS Boards, Integrated Joint Boards, Public Health Scotland, Health and Social Care Partnerships, and the Third Sector.

# data[].attributes.attachment_link.title
‘He just gave up’: an exploratory study into the perspectives of paid carers on supporting older people living in care homes with depression, self-harm, and suicide ideation and behaviours | Ageing & Society | Cambridge Core

# data[].attributes.attachment_link.description
‘He just gave up’: an exploratory study into the perspectives of paid carers on supporting older people living in care homes with depression, self-harm, and suicide ideation and behaviours - Volume 40 Issue 5

# data[].attributes.attachment_link.readable_text
Mark and Ros Dowey said their 'world has been shattered' since losing their son to suicide in December 2023, as Digital Producer Sam Leader reports Play Brightcove video
When Murray Dowey left his parents watching television downstairs to go up to his bedroom he was a happy sixteen-year-old boy.

Just hours later, Murray had taken his own life, having become the latest victim of a surge of sextortion cases in the UK.

Murray, 16, from Dunblane was contacted on social media by someone claiming to be a young girl but was actually a scammer, who tricked him into sending an intimate image and then blackmailed him with it.

Speaking for the first time about their son's case, Murray's parents told ITV News their "whole world has been shattered".

At Murray's local football club, Stirling Albion, where he spent every weekend with his friends, Mark and Ros Dowey said they "don't want this to happen to any other family" and called on social media platforms to up the safeguarding for teenagers "immediately".

They share their story as ITV News are given exclusive stats that reveal the UK's only helpline dedicated to helping victims of intimate image abuse received 54% more sextortion reports in 2023, than the previous year.

Sextortion, is when intimate images and/or videos are recorded and used for financial exploitation and coercion; It is mostly committed by organised criminal gangs overseas.
'The next thing I heard was Ros screaming, screams like I've never heard in my life before'
Reports to The Revenge Porn Helpline doubled last year reaching nearly 19,000, but sextortion made up over a third of those reports, and is the main form of intimate image abuse reported to the helpline - 93% of those cases were reported by men.

Mark and Ros Dowey said there 'world has been shattered' since losing their son

Murray had been enjoying festive celebrations last year with his parents and his two brothers, before going up to his room as normal, but his family "never for a minute thought that was the last time [they] were going to see him."

Ros Dowey, Murray's mother, said: "That evening we were just chatting and watching rubbish on telly... We were just a normal family of five.

"To the next morning, we're down to four people with a huge Murray-shaped gap that's never going to go away.

"He's my little boy. To think of my little boy in such distress and not to reach out for help, it's awful."

Murray took his own life on December 30, 2023, just hours after he was blackmailed by a scammer.

Mark Dowey, Murray's father, said he was "sitting watching the football, next thing I heard was Ros screaming, screams like I've never heard in my life before... it was horrendous."

"He was a very normal, easygoing, helpful boy, had a great sense of humour... I can't believe he's gone.
'We thought we were dealing with suicide... [it was] absolute torture'
"One of the reasons it is so devastating as it comes into your house, exactly where Murray should have been safest in his room, asleep. So there's very little you can do to protect them."

For two weeks, before police confirmed that Murray had been a victim of sextortion, Mark and Ros were left questioning everything they knew about their son's mental wellbeing.

Murray was a season ticket holder at his local club Stirling Albion Credit: Family handout

Ros told us: "He was a normal, happy teenager... he had plans. He had everything to look forward to... he was talking about saving up for a summer holiday with his friends.

"The panic and terror he must have been in for however long this went on, whether it was minutes or hours, I'm devastated for him, that he was just obviously in such a state that he thought taking his life was the only thing he could do.

"We'd had lots of conversations with our boys about online safety [and] social media... you'd never, ever imagine it's going to hit you because you're just a 'normal family' and these things don't happen."Mark said: "We thought we were dealing with suicide... [it was] absolute torture... indeed he did take his own life but he was very much taken to that point by these criminals."

"As parents, were very good at telling kids what not to do, but maybe not so good at telling them what to do if they do do it.
'I just think they're evil...those criminals killed our son.'
"I think that's something we really need to take away from this, that you need to give them that information, that if they do step over that line, don't panic. Don't do what Murray did."

Police Scotland are working with authorities in Nigeria to find the perpetrator responsible and to get justice for Murray.

Murray's parents, Mark and Ros, stand next to his seat at Stirling Albion FC

Sextortion scams can be perpetrated by individuals but the majority are committed by organised crime groups operating overseas, who often target young men with fake images, before blackmailing them for money.

Ros Dowey said: "I just think they're evil...those criminals killed our son. they can't just be anonymous people behind the keyboard thousands of miles away.

"There has to be consequences and there has to be consequences to deter others from doing this."

Mark said: "That demographic has been chosen very specifically by these criminals for their vulnerability to this crime."

In a statement to ITV News, Superintendent Joanne McEwan, from Police Scotland's Partnerships, Prevention and Community Wellbeing Department said: "We are experiencing an increase in the number of sextortion incidents being reported and organised crime gangs based overseas are often responsible, although individuals are also involved.
'It just breaks your heart that that's what his last moments on earth were... just that terror'
"People shouldn't panic, there is support available from policing and from third party organisations. We encourage victims to come forward. They will be treated with respect and dignity and the circumstances investigated professionally."

Not only do Murray's family now face a battle to get justice for their son, they want to put pressure on social media platforms to do more for young peoples safety, and ensure no other family loses a child under these circumstances.

Mark Dowey said: "I think the the platforms that these criminals are using need to up the safeguarding, up the protection for young people immediately. I think they know exactly how they could do that. It's been mooted by many an expert, but nothing's been done about it.

"We're starting to see a lot of young people dying through this crime."

Mark added: "I would very much like to say to young people if this is happening to you, that is your absolute route out of it, just switch the phone off and walk away from it. Get help. Go and get help."

Ros Dowey said: "There's all sorts of technologies they can be using because these criminals have a real pattern of behaviour... But I also think the [social media] platforms need to make it easier for children to report a scam and then they act on it really quickly.

"More needs to be done in schools and other forms of education to raise awareness to young people that that this can happen and this is what you do when this happens...

Murray's parents described him as the 'peacemaker' and the 'glue' between his two brothers Credit: Family Handout

"And for parents to be aware of it and to not sit there and think it's some abstract thing that couldn't happen, you know, it can happen to anybody."

Ros now wants other young people to know that if they do become a victim to sextortion, that "nothing is that bad, that it's worth taking your own life".

She added: Murray "hated being the centre of attention, so the thought that they were going to share this with all his contacts would have felt like the end of his world, but it wouldn't have been.
Revenge Porn Helpline's Amanda Dashwood explains what to do if you are a victim of sextortion
"We'd have gotten over it. We'd have helped him through it... rather than what we have now which is no Murray, and we have to live with that for the rest of our lives."

(Campaign Against Living Miserably) - Helpline: 0800 58 58 58

provides to empower anyone experiencing a mental health problem. Information line: 0300 123 3393

is an organisation offering confidential support for people experiencing feelings of distress or despair. Phone 116 123 (a free 24 hour helpline).

How to get help if you have been affected by the issues mentioned in this article:

# data[].attributes.attachment_link.title
'They killed our son': The devastating impact of sextortion scams as cases soar | ITV News

# data[].attributes.attachment_link.description
Murray Dowey, a 16-year-old from Dunblane, took his own life after he was "sextorted" by a scammer. | ITV National News

# data[].attributes.attachment_link.title
Whatever's on your mind, we're here - Togetherall

# data[].attributes.attachment_link.description
Need urgent help? Contact one of these crisis support services

# data[].attributes.attachment_link.readable_text
Suicide Prevention in the Community (2023) - Connecting, Communicating, Caring: A Practical Guide aims to offer practical, evidence-based guidance to help and encourage communities who want to get involved in suicide prevention by building their understanding, knowledge and skills.

It promotes consistent and safe messages and provides information on how to respond to suicide in a balanced and sensitive way. Informed by experiences and knowledge built up over the years, real-life case study examples are outlined of activities, initiatives and programmes being carried out throughout Ireland.

This book was produced by Mary O'Sullivan (HSE Resource Officer for Suicide Prevention) in collaboration with HSE colleagues, and other statutory, voluntary and community groups working in suicide prevention in Ireland. It was edited by Eithne Tiernan and published by the HSE National Office for Suicide Prevention (NOSP) in 2023.

# data[].attributes.attachment_link.title
Suicide Prevention in the Community - HSE.ie

# data[].attributes.attachment_link.description
Suicide Prevention in the Community (2023) - Connecting, Communicating, Caring: A Practical Guide

# data[].attributes.attachment_link.readable_text
Publisher's Synopsis

In this comprehensive guidebook, Joy Hibbins (the founder of an award-winning Suicide Crisis Centre which has attracted international attention) shares her invaluable experience of helping people through suicidal crisis.

Equally popular with the public and professionals, the book provides the reader with strategies and skills to help someone through a period of suicidal crisis.

Whether you have never helped someone in crisis before, or you already have an abundance of experience, this book is relevant for you.

The charity that Joy runs (Suicide Crisis) regularly provides suicide prevention training for the NHS, the British Transport Police and charities.

This book will show you how to:
Understand the complexity of suicidal feelings and what may lead to a crisis
Be aware of factors that can increase someone's risk of suicide
Assess risk and directly ask someone about suicidal thoughts
Build empathy and a strong connection with the individual in crisis
Create a safety plan
Learn strategies and skills to help someone survive (in the short-term and the longer term)
Learn techniques to support someone who is experiencing intense distress - or conversely someone who is silent and withdrawn
Create manageable steps to help someone survive
Know what to say, including how to help someone see their own worth
Understand why some people experience multiple crises and how to help them

All royalties donated to the charity Suicide Crisis.

# data[].attributes.attachment_link.description
The information and confidence you need to help friends, work colleagues and loved ones suffering from suicidal thoughts, or following a suicide attempt. This b

# data[].attributes.attachment_link.title
Home - Self-Harm Network Scotland Penumbra

# data[].attributes.attachment_link.description
What is self-harm? Self-harm is any non-accidental behaviour which causes, or has the potential to cause, harm to a person. Self-harm is where someone hurts themselves as a way of coping with difficult, distressing or overwhelming feelings or experiences. While we know that self-harm and suicide are linked, we also know that self-harm is often [...]

# data[].attributes.attachment_link.readable_text
Key points

The unique factors which contribute to suicide actions in later life are often more difficult to recognise than contributing factors in younger individuals.

Suicide thought may be passively expressed and can be triggered by the experience of existential loneliness or a sense of a 'completed life'. This can give rise to self-neglect, particularly of one's own health, and death hastening behaviour such as the voluntary stopping of eating and drinking, as well as more purposive suicide acts.

Taking a life course including a trauma-informed approach can help practitioners identify contributory risk and protection factors.

Ageism and stigma can mean that suicidal thought and action are less likely to be recognised in later life.

Existing suicide prevention interventions are not sufficiently nuanced for older people.

Practitioner skills and knowledge on how to screen, approach and discuss the topic of suicide in later life should draw on principles of time, space, and compassion.

Introduction

Suicide prevention is a priority for public health. The United Nations and the World Health Organization have coordinated a global response to suicide prevention (WHO, 2014). In the UK, suicide prevention strategies are developed by its four devolved governments. Documentary analysis of sampled strategies, however, revealed that these strategies say relatively little about people in later life (Hafford-Letchfield and colleagues, 2021).

Suicide rates in many countries are higher among older people in comparison with other age groups (Shah and colleagues, 2016). An analysis of trends in deaths by suicide over the past five years in Scotland shows that rates of suicide have fallen for most age groups, except for those aged 45-54 years and in females aged 55-64 years (Barry and colleagues, 2022). More recently, age related data on completed suicide in Scotland shows an increasing trend over the age of 65 since 2020 (NRS, 2022). High rates of suicide among older adults are thought to be a consequence of the ageing population demonstrating more determined and planned suicide acts, coupled with fewer warnings, or detection of suicidal intent. For instance, self-harm and suicide behaviour in older people is more likely to result in death, compared to younger age groups (Monforte-Royo and colleagues, 2011; Wand and colleagues, 2018).

The prevalence of suicide in later life may also be under-estimated and under-recorded due to its unique presentation. Deaths in older people that result from more passive acts of suicide, such as the voluntary stopping of eating and drinking (VSED) and refusing medication, are unlikely to be formally investigated as potential suicide deaths and are, therefore, less likely to be recorded (Deuter and colleagues, 2016). Such acts may be considered a rational decision, or interpreted as a legitimate exit, when people experience dramatic changes in social status and role (Berniere and colleagues, 2020; Hafford-Letchfield, 2022a).

Ageism in society has also been identified as a barrier to people seeking help and getting support (Ayalon and Shiovitz-Ezra, 2011). Structural ageism and internalised stigma can promote views that poor physical and mental health is a normal part of ageing, which may in turn not be routinely investigated or treated (Stanley and colleagues, 2016).

The field faces challenges in relation to how suicide thought and behaviour in later life is recognised, and whether a specific model for late life suicide can provide an enhanced understanding of the ageing experience (Van Orden and Conwell, 2016). An emerging body of evidence articulated in this guide describes how aetiology, epidemiology and presentation of suicide thought and actions during later life is a different phenomenon from that experienced in other times of the lifecourse.

Aims

This Insight is targeted at:

Practitioners who work with older people and may want to know more about how to address suicidal thought and behaviour in this population

Specialist suicide prevention providers who are interested in tailoring their existing services for people in later life (by 'later life' we mean people aged 65 years or older)

It summarises the key messages from the research evidence and emerging themes on how to improve recognition, responsiveness, and access to support.

The policy context

The Scottish Government and the Convention of Scottish Local Authorities (COSLA) developed Scotland's Suicide Prevention Plan (2022-2025), Creating hope together. This makes specific reference to older adults in outcome three and action area five. It calls for a compassionate response and to develop new approaches to prevent suicidal behaviour in older adults, with a focus on delivering action in key settings. This includes engaging with people with lived experience; reviewing and synthesising the evidence around the needs, risk and protective factors; effective responses; and implementing learning from reviews of suicide deaths in older adults.

While the plan addresses the suicide prevention needs of the whole population - especially where there are known risk factors, such as poverty, or being from marginalised or minority groups - there is less research and fewer interventions aimed at suicide prevention skills specific to people in later life. A fairer Scotland for older people (Scottish Government, 2019) aims to address barriers and deliver improvement that tackles inequalities for people in later life that are also known to impact on suicide. There are resources available to enhance the capacity of the workforce in this area through building skills and knowledge (NHS Scotland and Public Health Scotland, 2022).

Overview of the body of evidence

Research suggests that there are a range of unique factors that contribute to suicide thought and behaviour in later life. These include increased social isolation, childhood and/or life-long trauma(s), cumulative loss and complicated bereavement experiences, financial distress, material disadvantage, feeling like a burden and deteriorating health that can increase with age (De Leo, 2022; Hafford-Letchfield and colleagues, 2022b).

There have been several reviews exploring ageing in relation to suicidal behaviours. Some have focussed on exploring this topic from a theoretical point of view (Stanley and colleagues, 2016), while others have focussed on specific risk factors such as socioeconomic status (Ju and colleagues, 2016), the social determinants of health (Carvalho and colleagues, 2020; Dautovitch and colleagues, 2021) and gender (Heisel and colleagues, 2020).

A conceptual framework for suicide-related expression in later life

Hafford-Letchfield and colleagues (2022b) developed a conceptual framework from a scoping review of the literature which describes how we might better understand the pathways to suicide in later life. This framework captures the complexity of terminology used to describe suicide related behaviours and presentations unique to ageing. This provides a first step in helping policy makers, researchers, professionals, and people who work and live with older adults to progress towards identifying more tailored preventive measures and early interventions targeting suicide-related behaviours that are unique to, but common in, later life. The remainder of this Insight draws on this conceptual framework to summarise some of the key themes from this body of work.

Four key concepts on suicide expression in later life, the relationship between each, and factors that protect against their development are described in Figure 1 (below).

Viewing life as 'completed'

Behaviour that hastens death

Self-destructive behaviour

Protective factors: social connectedness; satisfaction in one's social life; high level of purpose; perceived control over one's life; low levels of perceived burdensomeness and/or hopelessness; low levels of functional disability.

Figure 1. A conceptual model of the 'grey areas' of suicide-related expression in later life (Hafford-Letchfield and colleagues, 2022b)

The four concepts are:

1. Completed life and existential loneliness (including feeling 'tired of life')

2. Death wishes, thoughts, and ideation

3. Death hastening behaviours and advanced directives (eg, voluntary stopping of eating or drinking)

4. Self-destructive or self-injurious behaviours (including self-neglectful behaviours).

Based on the identified protective factors, we recommend that those working in social care and social work aim to develop an enhanced understanding of older individuals' conditions or attributes (living environment, conditions, skills, strengths, resources, personal character, support networks or coping strategies). This will aid strategies designed to enhance protective factors, as well as inform the development of any psychosocial or peer-led interventions to prevent the development of the identified suicide expressions.

Viewing life as completed

Richards (2017) described a 'sense of a completed life' as feeling unable or unwilling to connect or feeling disconnected with life. A major theme was the person's anxiety about further loss of self-determination and self-sufficiency in their future. Existential loneliness has been differentiated from other types of loneliness where people feel isolated and acutely aware of their own mortality. A synthesis of studies (Bolmsjö and colleagues, 2019) revealed that failure to have needs met in a crisis and lack of authentic communication gave rise to overwhelming negative feelings, emotion or moods including sadness, hopelessness, grief, meaninglessness and anguish.

Developing a wish to die

Monforte-Royo and colleagues (2011) talk about the lack of terminological and conceptual precision in defining the construct of death ideation in later life, and the need to distinguish between a generic wish to die, the explicit expression of a wish to die, and a request for euthanasia or physician-assisted suicide.

Further differentiation between thoughts, wishes and intentions has been associated with a diagnosis of depression (Raue and colleagues, 2010) which is significantly associated with increased mortality. However, Fässberg and colleagues (2012) found that most of their participants (77.4%) who reported thinking about their own death at least once per month were not diagnosed as depressed.

Studies exploring why a wish to die in later life develops, point to feelings of being a burden and hopelessness (Guidry and Cukrowicz, 2016); a dissatisfaction in one's social life (Bernier and colleagues, 2020); viewing one's life as having no purpose; and perceiving a lack of control over one's life (Bonnewyn and colleagues, 2014). Changes in health that impact day to day functioning (Fässberg and colleagues, 2016), problematic drug and alcohol use (Cavalcante and Minayo, 2015) and personal experience of violence, and abandonment in earlier life, are also associated with the wish to die.

These findings suggest that a wish to die by suicide is expressed in highly complex ways through an older person's life course. Personal character, coping strategies and social support play a role in the way that individuals deal with challenging events or situations (Rurup and colleagues, 2011). Balancing positive and negative feelings towards living and dying was important in whether the person went on to complete suicide (Van Wijngaarden and colleagues, 2016).

Behaviours that hasten death

Actions that hasten death may include voluntary and or/deliberate stopping of eating and drinking (VSED), which highlight ethical debates and considerations (Rodríguez-Prat and colleagues, 2018). Advanced directives, for example, can be extremely complex where the person is living with dementia (Steinbock and Menzel, 2018; Trowse, 2020).

Stängle and colleagues (2019) attempted to distinguish between different forms of VSED, its cause and associated intentions. Exploring meaning in the wish to hasten death in patients with advanced illness indicated that VSED may be a response to physical, psychological and/or spiritual suffering; a means of taking control and a deliberate expression of personal autonomy (Rodríguez-Prat and colleagues, 2018). The research indicates the importance of exploring all possible areas of distress to include existential and social aspects, as well as the legal context.

In England, care staff participating in a study by Hafford-Letchfield, and colleagues (2020) described a sense of helplessness in not knowing what to do when care home residents 'gave up' (ie, engaged in death hastening behaviours). Staff expressed tensions in providing the right support and creating spaces to respond to such challenging situations. Person-centred care helped to alleviate personal stressors, as did investment in relationships within which the resident could confide and express themselves. Building a team around them required appropriate expertise and indicated a need for improved training. Engaging residents in expressing their wishes around dying, care and safety planning particularly when transitioning into more dependent care was recommended in supporting older people living their final years in care home settings.

Self-destructive behaviour

This can include self-harm, indirect and direct self-destructive or self-injury through purposive actions. A review of the prevalence, risk factors and characteristics of self-harm in later life (Troya and colleagues, 2019) found moderate evidence that a previous history of self-harm, previous and current psychiatric treatment, and sociodemographic factors (single, living alone and younger older adults aged 60-74 years old) were significant risk factors for repletion of self-harm. Alcohol/drug use, female gender, psychiatric history, and a diagnosis of musculoskeletal conditions such as arthritis were also associated with repetition of self-harm.

One review looked at self-injurious behaviour in people with dementia living in nursing homes (Mahgoub and colleagues, 2011). The most common direct self-injurious behaviour included self-pinching, scratching, and banging one's fist against objects or less commonly, pulling one's own hair and self-hitting. Wand and colleagues (2018) examined the reasons why older people have self-harmed and suggested that both active and passive self-harm should be considered as distinct entities as the underlying motivations and intentions differ. They also observed that for some older people self-neglect may reflect impaired coping skills or cognitive impairment.

Older adults who self-harm have a sixty-seven times higher risk of suicide compared with younger populations (Murphy and colleagues, 2012). There is increased risk of repetition in those with a previous history (Troya and colleagues, 2019). Socio-demographic factors including being single, living alone and being a younger older adult (60-74 years old), were more strongly associated with its repetition. Time spent in hospital with self-harm is longer and medical complications are more likely. As most studies are based in hospital settings, our knowledge of self-harm is not representative. It does not consider self-harm that does not result in hospital admission.

Troya and colleagues' (2019) study focussed specifically on self-poisoning which they found to be distinctive in later life compared with other populations. This is possibly due to increased access to prescribed medication for complex health problems and antidepressants (Hedna and colleagues, 2020).

Screening, assessment and help-seeking

A key feature in preventing suicide is to accurately and routinely assess and screen for suicide ideation. There is a need for more age-specific screening and diagnostic measures (Gleeson and colleagues, 2021).

Currently, there is little consensus as to how best to screen for suicide ideation in older people and how to assess wider factors described earlier. This points to the need for holistic psychosocial assessment. Professionals may lack training in how older people express concerns about their mental health, or in recognising the subtle clues that suggest more passive expressions of suicide.

Screening of suicide ideation in older people is not routine across settings, especially outside of health (Gleeson and colleagues, 2021). Numerous studies have highlighted a reluctance to speak openly about mental health among this generation (eg, Hafford-Letchfield and colleagues, 2022a). In contrast, there is a preference for talking therapies among older people given that those over 85 years are up to a third more likely to be prescribed antidepressants compared to those between 55 and 85 years (Frost and colleagues, 2020).

Older people, however, may not be offered talking therapies. They may be reluctant to discuss psychological or emotional distress with care professionals, have low expectations and experience self-stigma (Hafford-Letchfield and colleagues, 2022a). Many older people who die by suicide have been shown to have visited a GP in the previous 30 days where they discussed problems that were somatic in nature rather than psychological (Neufeld and O'Rourke, 2009). Additionally, GPs report that they do not always have the time and sensitivity needed to properly uncover and respond to these issues (Frost and colleagues, 2018).

Suicide screening may also decrease with increasing age. Wider screening for suicide ideation in older people, across a range of social care settings, may be indicated. Screening and assessment could take more account of protective factors by asking questions about social connections and support and to ensure cultural sensitivity towards marginalised groups (Gleeson and colleagues, 2021). Helping people to identify risk reduction interventions, such as therapeutic support and collaborative safety planning, could lead to enhanced safety and quality of care, which is more acceptable to people. It promotes a sense of hope and agency (McLaren and colleagues, 2022) by identifying and encouraging an individual's own psychological resources and resilience in working towards their own goals when challenges arise. A study of lay perspectives on suicide thought in later life (Hafford-Letchfield and colleagues, 2022) identified that relationship and language are key in enabling discussion and the importance of professionals learning to identify implicit/passive suicidal expressions in later life and being willing to take up opportunities to address it.

Bereavement by suicide

While there is some work to explore suicide bereavement support (McDonnell and colleagues, 2020; Scottish Government, 2022) there is limited work focussing on the experiences of suicide bereavement of those aged 60 years old and over. Only two studies have specifically explored age related factors on the impact of a suicide and how people re-orientate their later lives after such a devastating loss (Hyboldt and colleagues, 2020; Hafford-Letchfield and colleagues, 2021).

The absence of suicide bereavement support at any stage in life, contributes to a person's lack of self-care, and for some, leads to extreme post-traumatic stress. For example, the loss of a significant person by suicide can heighten the awareness of growing older alone and developing a fear of becoming more vulnerable (Hafford-Letchfield and colleagues, 2021; Hyboldt and colleagues, 2020). Experiencing a bereavement by suicide can also increase the likelihood of subsequent suicidal behaviours for the bereaved (Hafford-Letchfield and colleagues, 2021).

The practice implications of these findings point to asking about history of suicide bereavement and how this experience has affected the person's life and their current wellbeing.

Summary

Early detection of expression of these different areas is crucial. Expressions of living a completed life may transition to a desire to die or attempts to hasten death (Hafford-Letchfield and colleagues, 2020), and appear to precede direct suicide attempts (Kjølseth and colleagues, 2010). Being able to differentiate these from a broader acceptance by people that their lives are coming to an end or the sense of a completed life, is important as a wish to die can manifest independently of diagnosed depression. There are also wider narratives on the value of some people's lives over others, and tensions with desires for agency and control. These are reflected in the debates on euthanasia and assisted dying (Scottish Parliament, 2019).

More importantly, the belief that life is not worth living is likely to represent dissatisfaction with quality of life and is essential to discuss with individuals facing such circumstances - as are wishes to die/suicide ideation. This calls for closer examination of the impact of service culture and service quality on people's experiences.

Implications for the social services workforce

Adopt the right approach

Practitioners supporting or caring for older people need the right language, confidence, and skills to discuss issues concerning suicide thought and actions in later life. This is required for them to take the initiative and articulate their concerns when these are observed. It includes knowing where and when to sensitively seek appropriate and expert advice and support, and being able to access learning resources to enhance the capacity of the workforce in this area through building skills and knowledge (NHS Scotland and Public Health Scotland, 2022).

Develop early intervention strategies

The development of early intervention and prevention strategies in response to early expression could focus on protective factors that addresses the range of issues that contribute to suicide thought and behaviour such as promoting participation, autonomy and person-centred support.

Undertake training

Given the risk of suicide in later life, and some of the unique ways in which it may be expressed (existential loneliness, wish to die, self-neglect), all staff working with people in later life should be trained to recognise and improve awareness at the everyday level. This is where subtle interactions take place, such as in personal care or in the person's own home environment. Interdisciplinary work can encourage ethical reflexivity in relation to improving the quality of life of people who prefer to die than to continue living.

Encourage participation

Involve people and their carers in discussing mental health and wellbeing in later life. Consider community asset-based approaches that compliment medical interventions to address common issues such as loneliness, and that tackle the interpersonal and structural impacts of ageism.

Normalise discussion about completed life

Recognise the impact of service culture and service quality on people's experiences. Make active use of tools that promote end of life planning and advanced directives. Normalise opportunities to talk, review and express people's thoughts and fears about their completed life without being silenced or accused of being morbid, and use care plans to revisit and review any concerns about mental health and suicide ideation.

Be trauma informed

Adopt a trauma-informed approach to service delivery, acknowledging the importance of adopting a non-pathologizing and strengths-based approach to help prevent possible re-traumatisation of older adults within practices.

References

Ayalon L and Shiovitz-Ezra S (2011) The relationship between loneliness and passive death wishes in the second half of life. International Psychogeriatrics, 23,10, 1677-1685

Barry S, Bates E and Murray C (2022) Suicide statistics: technical paper. Scottish Public Health Observatory, Public Health Scotland

Bernier S, Lapierre S and Desjardins S (2020) Social interactions among older adults who wish for death. Clinical Gerontologist 43, 4-16

Bolmsjö I, Tengland PA and Rämgård M (2019) Existential loneliness: an attempt at an analysis of the concept and the phenomenon. Nursing Ethics, 26, 5, 1310-1325

Bonnewyn A, Shah A, Bruffaerts R et al (2014) Are gender and life attitudes associated with the wish to die in older psychiatric and somatic inpatients? An explorative study. International Psychogeriatrics, 26, 10, 1693-1702

Carvalho ML, Costa APC, Monteiro CFS et al (2020) Suicide in the elderly: approach to social determinants of health in the Dahlgren and Whitehead model. Revista Brasileira de Enfermagem 73, e20200332

Cavalcante FG and Minayo MCDS (2015) Qualitative study on suicide attempts and ideations with 60 elderly in Brazil. Ciencia & Saude Coletiva, 20, 1655-1666

Dautovich ND, MacPherson A, Reid M et al (2021) A narrative review examining intersections of identity in older adult suicidality. Aggression and Violent Behavior, 57, 1015-16

De Leo D (2022) Late-life suicide in an aging world. Nature Aging, 2, 7-12

Diehl-Schmid J, Jox R, Gauthier S et al(2017) Suicide and assisted dying in dementia: what we know and what we need to know. A narrative literature review. International Psychogeriatrics, 29, 1247-1259

Deuter K, Procter N, Evans D et al (2016) Suicide in older people: revisioning new approaches. International Journal of Mental Health Nursing, 25, 2, 144-50

Fässberg MM, Van Orden KA, Duberstein P et al (2012) A systematic review of social factors and suicidal behavior in older adulthood. International Journal of Environmental Research and Public Health, 9, 722-745

Fässberg MM, Cheung G, Canetto SS et al (2016) A systematic review of physical illness, functional disability, and suicidal behaviour among older adults. Aging & Mental Health, 20, 166-194

Frost DA, Snydeman CK, Lantieri MJ et al (2020) Development and implementation of a suicide prevention checklist to create a safe environment. Psychosomatics, 61, 20, 154-160

Gleeson H, Roesch C, Hafford-Letchfield T et al (2021) Assessing suicide ideation among older adults: a systematic review of screening and measurement tools. International Psychogeriatrics, 34, 5, 439-452

Guidry ET and Cukrowicz KC (2016) Death ideation in older adults: psychological symptoms of depression, thwarted belongingness, and perceived burdensomeness. Aging & Mental Health, 20, 823-830

Hafford-Letchfield, T, Gleeson H, Ryan P et al (2020) 'He just gave up': an exploratory study into the perspectives of paid carers on supporting older people living in care homes with depression, self-harm, and suicide ideation and behaviours. Ageing and Society, 40, 5, 984-1003

Hafford-Letchfield T, Hanna J, Grant E et al (2021) Bereavement by suicide in later life: project report. Glasgow: University of Strathclyde

Hafford-Letchfield T, Hanna J, Grant E et al (2022) "It's a living experience": bereavement by suicide in later life. International Journal of Environmental Research Public Health 2022, 19, 7217

Hafford-Letchfield T, Hanna JR, Ellmers TJ et al (2022a) Talking really does matter: lay perspectives from older people on talking about suicide in later life. Frontiers Psychology 13:1009503

Hafford-Letchfield T, Jain B, Gleeson H (2022b) A scoping review exploring the 'grey area' of suicide-related expression in later life: developing a conceptual framework for professional engagement. Ageing and Society, 1-30

Hedna K, Hensing G, Skoog I et al (2020) Sociodemographic and gender determinants of late-life suicide in users and non-users of antidepressants. European Journal of Public Health, 30, 5, 958-964

Heisel MJ, Neufeld E and Flett GL (2016) Reasons for living, meaning in life, and suicide ideation: investigating the roles of key positive psychological factors in reducing suicide risk in community-residing older adults. Aging and Mental Health, 20, 195-207

Hybholt L, Buus N, Erlangsen A et al (2020a) Older adults bereaved by suicide: a systematic literature search identifying zero studies. Arch. Suicide Res., 24, 119-124

Ju YJ, Park EC, Han KT et al (2016) Low socioeconomic status and suicidal ideation among elderly individuals. International Psychogeriatrics, 28, 12, 2055-2066

Kjølseth I, Ekeberg Ø and Steihaug S (2010) Why suicide? Elderly people who committed suicide and their experience of life in the period before their death. International Psychogeriatrics, 22, 2, 209-218

Mahgoub N, Klimstra S, Kotbi N et al (2011) Self-injurious behavior in the nursing home setting. International Journal of Geriatric Psychiatry, 26, 27-30

McDonnell S, Flynn S, Shaw J et al (2020) Suicide bereavement in the UK: descriptive findings from a national survey. Suicide and Life-Threatening Behaviour, 52, 5, 887-897

Monforte-Royo C, Villavicencio-Chávez C, Tomás-Sábado J et al (2011) The wish to hasten death: a review of clinical studies. Psycho-Oncology, 20, 795-804

NHS Education Scotland and Public Health Scotland (2022) Mental health improvement, and prevention of self-harm and suicide

National Records Scotland (NRS) (2022) Probable Suicides, 2021

Neufeld E and O'Rourke N (2009) Impulsivity and hopelessness as predictors of suicide-related ideation among older adults. Canadian Journal of Psychiatry, 54, 684-692

Raue PJ, Morales KH, Post EP et al (2010) The wish to die and 5-year mortality in elderly primary care patients. The American Journal of Geriatric Psychiatry, 18, 4, 341-50

Richards N (2017) Old age rational suicide. Sociology Compass, 11, e12456

Rodríguez-Prat A, Monforte-Royo C and Balaguer A (2018) Ethical challenges for an understanding of suffering: voluntary stopping of eating and drinking and the wish to hasten death in advanced patients. Frontiers in Pharmacology, 9, 79-105

Rurup ML, Pasman HRW, Goedhart J et al (2011) Understanding why older people develop a wish to die: a qualitative interview study. Crisis, 32, 204-216

Scottish Government (2019) A fairer Scotland for older people: framework for action

Scottish Parliament assisted dying bill (2019)

Scottish Government and COSLA (2022) Creating hope together: Scotland's suicide prevention plan 2022-2025

Scottish Government (2022) Suicide bereavement support service - year one: evaluation summary

Shah A, Bhat R, Zarate-Escudero S et al (2016) Suicide rates in five-year age-bands after the age of 60 years: the international landscape. Aging & Mental Health, 20, 131-138

Stängle S, Schnepp W and Fringer A (2019) The need to distinguish between different forms of oral nutrition refusal and different forms of voluntary stopping of eating and drinking. Palliative Care and Social Practice, 13, 1-17

Stanley IH, Hom MA, Rogers ML et al (2016) Understanding suicide among older adults: a review of psychological and sociological theories of suicide. Aging & Mental Health, 20, 113-122

Steinbock B and Menzel PT (2018) Advance directives for refusing life-sustaining treatment in dementia. Hastings Center Report, 48, S75-S79

Trowse P (2020) Voluntary stopping of eating and drinking in advance directives for adults with late-stage dementia. Australasian Journal on Ageing, 39, 142-147

Troya MI, Babatunde O, Polidano K et al (2019) Self-harm in older adults: systematic review. British Journal Psychiatry. 214, 4,186-200

Van Orden KA and Conwell Y (2016) Issues in research on aging and suicide. Aging & Mental Health, 20, 240-251

Van Wijngaarden E, Leget C and Goossensen A (2016) Caught between intending and doing: older people ideating on a self-chosen death. BMJ Open, 6, 1, e009895

Wand APF, Peisah C, Draper B et al (2018) Understanding self-harm in older people: a systematic review of qualitative studies. Aging & Mental Health, 22, 289-298

World Health Organization (WHO) (2014) Preventing suicide: a global imperative. Geneva: WHO

Acknowledgements

This Insight was reviewed by Barbara Billings (retired social worker and peer researcher); Naresh Mall (registered social worker); Merrick Pope (Royal Edinburgh Hospital); and Maria Dale, Gillian Davies and Suzanne Crooks (NHS Education Scotland).

Comments represent the views of reviewers and do not necessarily represent those of their organisations. Iriss would like to thank the reviewers for taking the time to reflect and provide feedback on this publication.

About the authors

Dr Trish Hafford-Letchfield is Professor of Social Work at the University of Strathclyde. She is a qualified nurse and social worker. Her research engages with the experience of ageing in marginalised communities. Trish has more than 100 publications in the field of leadership, management, LGBTQ+ issues in health and social care, feminism, lifelong learning, mental health and problematic substance use.

Dr Toby Ellmers is a Wellcome Trust Sir Henry Wellcome Fellow, at Imperial College London. His research investigates psychological functioning and physical wellbeing in older adults, particularly with respect to anxiety, fear of falling and physical frailty.

Dr Helen Gleeson is a Research Fellow in Social Work/Social Policy at Middlesex University. Her PhD in psychology explored the relationships between young people and the police in Ireland. Her research focuses on young people's experiences in the criminal justice system, substance use treatment service experiences of minority groups, suicide ideation in older people, and social work interventions for children on the edge of care. Her research broadly works across a range of projects within social work and mental health that have a specific focus on socially and economically marginalised groups.

Dr Nicola Cogan joined the University of Strathclyde in October 2017 having previously worked as a consultant clinical psychologist and clinical lead in mental health services in the NHS. She has over 15 years NHS experience working as a practitioner clinical psychologist in mental health services. She retains an honorary consultant clinical psychologist post in NHS Lanarkshire. She has a strong interest in mental health research and the use of participatory methods.

Dr Susan Rasmussen is a chartered health psychologist with many years' experience of conducting research to understand the reasons why people develop suicidal thoughts, and how these thoughts are at times translated into behaviours. She is a senior lecturer in the School of Psychological Sciences and Health at the University of Strathclyde where she is also a Centre for Health Policy Fellow. She is currently part of the academic advisory team which supports the leadership group responsible for the development and implementation of the Scottish Government's suicide prevention strategy. She also chairs the Research Ethics Committee for the Samaritans.

Jolie Goodman is an artist who has worked from a survivor perspective in mental health for over two decades. Before going freelance last year, she was Programmes Manager for Empowerment & Later Life for the Mental Health Foundation. Jolie's daily drawing practice can be seen on Instagram @jolie.goodman.

Dr Jeffrey R Hanna is a Research Associate at the Institute of Nursing and Health Research, Ulster University. His research interests and profile include cancer care, bereavement, suicide prevention and positive mental health outcomes. Alongside this, he is undertaking an MSc in Professional Nursing at Queen's University Belfast.

Credits

Series Coordinator: Kerry Musselbrook

Commissioning Editor: Kerry Musselbrook

Copy Editor: Michelle Drumm

Designer: Ian Phillip

# data[].attributes.attachment_link.title
Suicide thoughts and behaviour in later life

# data[].attributes.attachment_link.description
A summary for practitioners and suicide prevention providers who work with older people.

# data[].attributes.headline
Scottish Government Mental Health and Wellbeing Stragegy

# data[].attributes.subject
Scottish Government Mental Health and Wellbeing Stragegy

# data[].attributes.attachment_link.readable_text
1. Sources of support
Some of the content in this Strategy may have an emotional impact on you. Support is always available, and some of the national sources of help are listed here.
Mind to Mind

If you're feeling anxious, stressed or low, or having problems sleeping or dealing with grief, find out how you can improve your mental wellbeing by hearing what others have found helpful by visiting www.nhsinform.scot/mind-to-mind

Breathing Space

Breathing Space is Scotland's free, confidential listening service for individuals over 16 experiencing symptoms of low mood, depression or anxiety. You can contact them on 0800 83 85 87 Monday to Thursday from 6pm to 2am and 24 hours a day at weekends (from 6pm Friday to 6am Monday).

Samaritans

Samaritans provide confidential, non-judgemental emotional support 24/7 for people who are experiencing feelings of distress or despair. You can contact Samaritans free by phoning 116 123 or emailing jo@samaritans.org

NHS 24 Mental Health Hub

NHS 24 mental health services are available to everyone in Scotland. The services available include listening, offering advice and guiding you to further help if required. The Mental Health Hub is open 24/7 and you can contact them on 111.

Childline

Childline is a free service for children and young people for when they need support or advice. It is open 24/7, and there are many ways to get help. You can call 0800 1111 or visit their website www.childline.org.uk

# data[].attributes.attachment_link.description
A Strategy laying out the Scottish Government's approach to improving mental health for everyone in Scotland.

# data[].attributes.attachment_link.description
Read about what you may experience if you lose someone to suicide, and what help and support is available.

# data[].attributes.attachment_link.title
The Suicide Bereavement Survey at The University of Manchester

# data[].attributes.attachment_link.description
Listen to this episode from The University of Manchester Podcasts on Spotify. Dr Sharon McDonald discusses her work in suicide bereavement and the engagement her work has generated, as well as the invaluable support provided by ex-footballer Neville Southall. She credits his input with the surge in male respondents to her survey on mental health.

# data[].attributes.attachment_link.title
Survey reveals impact of suicide on family and friends

# data[].attributes.attachment_link.description
A study published today reveals over a third of those bereaved by suicide considered taking their own life, highlighting their acute need for more support.The team led by Dr Sharon McDonnell at The University of Manchester, in collaboration with the Support After Suicide Partnership, conducted the l…

# data[].attributes.attachment_link.description
Every year more than 700 000 people take their own life and there are many more people who attempt suicide.

# data[].attributes.attachment_link.description
Suicide? Help! - An information website as well as an Apple and Android app for people who are thinking about suicide or are worried about someone else.