Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death

Abstract

SummaryBackgroundSelf-harm is a major risk factor for suicide, with older adults (older than 65 years) having reportedly greater suicidal intent than any other age group. With the aging population rising and paucity of research focus in this age group, the extent of the problem of self-harm needs to be established. In a primary care cohort of older adults we aimed to investigate the incidence of self-harm, subsequent clinical management, prevalence of mental and physical diagnoses, and unnatural-cause mortality risk, including suicide.MethodsThe UK Clinical Practice Research Datalink contains anonymised patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. We identified 4124 adults aged 65 years and older with a self-harm episode ascertained from Read codes recorded during 2001–14. We calculated standardised incidence and in 2854 adults with at least 12 months follow-up examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. We estimated prevalence of mental and physical illness diagnoses before and after self-harm and, using Cox regression in a matched cohort, we examined cause-specific mortality risks.FindingsOverall incidence of self-harm in older adults aged 65 years and older was 4·1 per 10 000 person-years with stable gender-specific rates observed over the 13-year period. After self-harm, 335 (11·7%) of 2854 adults were referred to mental health services, 1692 (59·3%) were prescribed an antidepressant, and 336 (11·8%) were prescribed a tricyclic antidepressant (TCA). Having a diagnosed previous mental illness was twice as prevalent in the self-harm cohort as in the comparison cohort (prevalence ratio 2·10 [95% CI 2·03–2·17]) and with a previous physical health condition prevalence was 20% higher in the self-harm cohort compared to the comparison cohort (1·20 [1·17–1·23]). Adults from the self-harm cohort (n=2454) died from unnatural causes an estimated 20 times more frequently than the comparison cohort (n=48 921) during the first year. A markedly elevated risk of suicide (hazard ratio 145·4 [95% CI 53·9–392·3]) was observed in the self-harm cohort.InterpretationWithin primary care, we have identified a group of older adults at high risk from unnatural death, particularly within the first year of self-harm. We have highlighted a high frequency of prescription of TCAs, known to be potentially fatally toxic in overdose. We emphasise the need for early intervention, careful alternative prescribing, and increased support when older adults consult after an episode of self-harm and with other health conditions.FundingNational Institute for Health Research Greater Manchester Patient Safety Translational Research Centre.

Suicide and suicide risk

“…In addition, ample evidence supports the contributions of concurrent physical and mental illness (such as central nervous system and psychiatric disorders, inflammatory diseases, chronic obstructive pulmonary disorder and pain) to suicide risk 107,108 . Although impulsive-aggressive traits, substance abuse and conduct disorder make proportionally larger contributions to suicide risk in younger people 7,97,109 , depression, physical comorbidity, sleep and pain issues, and cognitive impairment are substantial contributors to suicidal behaviour in older people 110,111 . In terms of sleep problems, decreased sleep time, insomnia, and nightmares have been related to risk for suicidal behaviour 112 .…”

Patient and Public Involvement and Engagement in a doctoral research project exploring self‐harm in older adults

“…As an outcome of that study, PPIE members noted the importance of investigating self‐harm in older adults. This is a population which is often overlooked, yet recent studies suggest self‐harm in older adults results in increased mortality compared to younger groups . The group contributed to developing the idea as a doctoral research proposal and funding application, resulting in the doctoral research project presented here.…”

Self-harm in the very old one year later: has anything changed?

“…The sequelae of self-harm amongst the very old is not well understood. Previous self-harm regardless of intent (De Leo et al, 2002) is strongly associated with subsequent death by suicide (Morgan et al, 2018;Murphy et al, 2012). This may be because older people use more lethal methods, have greater intent to die, and less physiological resilience to self-harm (Bradvik and Berglund, 2009;Finkelstein et al, 2015;Miret et al, 2010).…”