A systematic review of evidence-based aftercare for older adults following self-harm

Abstract

Objective: Self-harm is closely associated with suicide in older adults and may provide opportunity to intervene to prevent suicide. This study aimed to systematically review recent evidence for three components of aftercare for older adults: (1) referral pathways, (2) assessment tools and safety planning approaches and (3) engagement and intervention strategies. Methods: Databases PubMed, Medline, PsychINFO, Embase and CINAHL were searched from January 2010 to 10 July 2021 by two reviewers. Empirical studies reporting aftercare interventions for older adults (aged 60+) following self-harm (including with suicidal intent) were included. Full text of articles with abstracts meeting inclusion criteria were obtained and independently reviewed by three authors to determine final studies for review. Two reviewers extracted data and assessed level of evidence (Oxford) and quality ratings (Alberta Heritage Foundation for Medical Research Standard Quality Assessment Criteria for quantitative and Attree and Milton checklist for qualitative studies), working independently. Results: Twenty studies were reviewed (15 quantitative; 5 qualitative). Levels of evidence were low (3, 4), and quality ratings of quantitative studies variable, although qualitative studies rated highly. Most studies of referral pathways were observational and demonstrated marked variation with no clear guidelines or imperatives for community psychiatric follow-up. Of four screening tools evaluated, three were suicide-specific and one screened for depression. An evidence-informed approach to safety planning was described using cases. Strategies for aftercare engagement and intervention included two multifaceted approaches, psychotherapy and qualitative insights from older people who self-harmed, carers and clinicians. The qualitative studies identified targets for improved aftercare engagement, focused on individual context, experiences and needs. Conclusion: Dedicated older-adult aftercare interventions with a multifaceted, assertive follow-up approach accompanied by systemic change show promise but require further evaluation. Research is needed to explore the utility of needs assessment compared to screening and evaluate efficacy of safety planning and psychotherapeutic approaches.

The characteristics, life problems and clinical management of older adults who self‐harm: Findings from the multicentre study of self‐harm in England

“…Common problems preceding self‐harm in the latter group include difficulties with employment, finance and alcohol misuse. Public health strategies should be designed to enable communities to improve access to psychiatric services as well as to address the multiple socio‐environmental factors which are relevant in older age, which can also be important in preventing both self‐harm and suicide, 38 but action requires an assertive approach accompanied by systematic change 39 . Referral to voluntary agencies and social prescribing may help reduce loneliness and improve physical and mental wellbeing, 40 which became particularly important in the context of the COVID‐19 pandemic.…”

“…Public health strategies should be designed to enable communities to improve access to psychiatric services as well as to address the multiple socio-environmental factors which are relevant in older age, which can also be important in preventing both selfharm and suicide, 38 but action requires an assertive approach accompanied by systematic change. 39 Referral to voluntary agencies and social prescribing may help reduce loneliness and improve physical and mental wellbeing, 40 which became particularly important in the context of the COVID-19 pandemic. Whilst our study data do not cover this period, it is important to acknowledge how the pandemic disproportionately affected this population both in terms of potential physical health consequences 41 and reduced social and emotional support 42 due to physical distancing and lockdowns.…”

A qualitative study of multiple voices to inform aftercare services for older persons following self‐harm

“…Provision of holistic Aftercare may be stymied by delays in accessing essential services such as home care packages, resulting in ongoing unmet need and, for some, premature admission to a RACF, both associated with self‐harm 12,33 . Lack of standardised pathways for older adults following presentation for self‐harm leads to ad hoc and missed referrals 7 . Participants noted this was especially true for older persons utilising private healthcare.…”

“…Older adults, particularly men over 85 years, have the highest rates of suicide across the lifespan in many countries 1,2 . Yet this is not well publicised and there are relatively few interventions targeting older adults for suicide prevention, 3 of which Aftercare is a core component. Aftercare, the coordinated follow‐up and management following self‐harm or attempted suicide, 4 has been associated with reduced risk of repeat suicidal behaviours 5,6 .…”

“…Older adults, particularly men over 85 years, have the highest rates of suicide across the lifespan in many countries. 1,2 Yet this is not well publicised and there are relatively few interventions targeting older adults for suicide prevention, 3 of which Aftercare is a core component.…”