Major changes needed to improve the care of older adults who self-harm
Older adults (aged 65 and older) who self-harm have a higher risk of dying from unnatural causes (particularly suicide) compared to their peers without a history of self-harm, according to a large observational study of UK primary care published in The Lancet Psychiatry journal.
Almost 90% of older adults who had harmed themselves, including overdosing on prescription drugs or self-cutting, were not referred for a specialist mental health assessment after visiting their general practitioner (GP), and the likelihood of referral was much lower for individuals living in socially deprived areas.
Additionally, contrary to national clinical guidelines a significant proportion (12%, around one in eight) of those who self-harm are prescribed a tricyclic antidepressant, which can be dangerous in overdose.
The study highlights the opportunity for earlier intervention in primary care to prevent repeated self-harm episodes and suicide in older adults.
"Older adults often face a decline in functional ability due to multiple comorbid conditions, bereavement, and social isolation, which are all strongly linked with self-harm. With the number of people aged over 65 set to rise to 25% of the UK population by 2046, healthcare services need to be aligned to meet both physical and mental health needs to ensure that vulnerable older people are identified and get the help and support they require." says Dr. Cathy Morgan, University of Manchester, UK, who led the research.
In recent years, there has been an increase in reports of suicide among older adults. In England and Wales between 2012 and 2015, suicide rates among men aged 60 and older rose from 12.3 to 14.8 per 100,000—which is higher than rates for male adolescents and younger male adults (10-29 years) at 10.6 per 100,000 in 2015. Suicide rates in older women have also increased over the past 5 years, converging toward those of younger women of working age (from 4.7 per 100,000 in 60-74 year olds vs 5.8 in 30-44 year olds in 2010 to 5.4 vs 6.0 in 2015). Self-harm among older people, however, has to date received comparatively little attention compared with younger age groups.
The researchers based their findings on recorded self-harm episodes among adults aged 65 years and older registered at 674 general practices in the UK between 2001 and 2014. They analysed data from the Clinical Practice Research Datalink, which is broadly representative of the UK population and is linked with hospital admissions, mortality records, and the area-level social deprivation (the Index of Multiple Deprivation). To investigate mortality risk after self-harm, they compared data from 2,454 of these patients with 48,921 patients without a history of self-harm (matched by age, gender, and general practice). Self-harm includes intentional injury and overdosing on prescription medication.
During the 13-year study period, 4,124 adults aged 65 years or older had an episode of self-harm recorded in general practice patient notes. Over half (58%) of these were women, and many (62%) had previously received mental health diagnoses.
Drug overdose was the most common method of self-harm (81%), followed by self-cutting (6%).
Importantly, only 12% (335/2,854) of over 65s who had self-harmed were referred to mental health services within 12 months of their initial self-harm episode.
Referrals were a third less likely for older adults registered at practices located in the most deprived areas (8%, 48/578) than those from more affluent communities (13%, 65/493), even though the incidence of self-harm was higher in these areas.
Almost three-quarters of people who had harmed themselves were prescribed psychotropic medications, most commonly antidepressants. Contrary to National Institute of Clinical Excellence (NICE) guidance, 12% (336/2,854) of older adults who self-harmed were prescribed a tricyclic antidepressant within a year of harming themselves.
One in seven (14.4%) older adults self-harmed again within a year of the initial episode.
Compared to the general population, older adults who had harmed themselves were twice as likely to have a history of a psychiatric illness (1,522/2,454 vs 14,455/48,921), and were 20% more likely to experience a major physical illness (1,760/2,454 vs 29,341/48,921) such as liver disease and heart failure.
Older adults who harmed themselves were also 19 times more likely to die from unnatural causes (mostly suicides, accidental poisonings, and other accidents) in the first year after a self-harm episode than the general population (29/330 vs 41/2,415 deaths), and 145 times more likely to die of suicide during the 13-year follow up—although suicide was rare in absolute terms (36 vs 12 deaths by suicide).
Co-author Professor Nav Kapur, University of Manchester, UK, adds: "We sometimes think of self-harm as a problem in younger people and of course it is. But it affects older adults too and the concerning issue is the link with increased risk of suicide. We hope our study will alert clinicians, service planners, and policy makers to the need to implement preventative measures for this potentially vulnerable group of people. Referral and management of mental health conditions are likely to be key."
According to co-author Professor Carolyn Chew-Graham, GP Principal in Central Manchester and Professor of General Practice at Keele University, UK: "Since drug ingestion is one of the main methods of self-harm, we highlight the need to prescribe less toxic medication in older adults for the management of both mental illness and pain related conditions. We also recommend more frequent follow-up of a patient following an initial episode of self-harm."
The authors point to several limitations of their study, including the possibility that some cases of self-harm may go unreported, and that statistics on suicide are likely to be underestimated perhaps due to cultural barriers or social stigma that discourage coroners from recording a conclusion of suicide.
Writing in a linked Comment, Associate Professor Rebecca Mitchell from the Australian Institute of Health Innovation, Macquarie University, Australia says: "Further research still needs to be done on self-harm among older adults, including the replication of Morgan and colleagues' research in other countries, to increase our understanding of how primary care could present an early window of opportunity to prevent repeated self-harm attempts and unnatural deaths. Exploration of self-harm and suicide risk among older adults in long-term care facilities has been scant. Little is known regarding the factors that might influence or be protective of the risk of self-harm among residents in long-term care compared with older adults living in the general community."