Changes needed to stem self-harm in older adults

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.

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 — 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 five years, converging towards those of younger women of working age (from 4.7 per 100,000 in ages 60–74 vs 5.8 in ages 30–44 in 2010 to 5.4 vs 6 in 2015). Self-harm among older people, however, has to date received comparatively little attention compared with younger age groups.

The UK 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. To investigate mortality risk after self-harm, they compared data from 2454 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, 4124 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%).

The study found that almost 90% of older adults who had harmed themselves were not referred for a specialist mental health assessment after visiting their GP, and the likelihood of referral was much lower for individuals living in socially deprived areas. This is of particular concern as non-fatal self-harm is the strongest risk factor for subsequent suicide, with older people reportedly having greater suicidal intent than any other age group.

Importantly, only 12% 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%) than those from more affluent communities (13%), 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 for Health and Care Excellence (NICE) guidance, 12% of older adults who self-harmed were prescribed a tricyclic antidepressant within a year of harming themselves, which can be dangerous in overdose. 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 and were 20% more likely to experience a major physical illness 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 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).

The study thus highlights the opportunity for earlier intervention in primary care to prevent repeated self-harm episodes and suicide in older adults.

“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,” said study co-author Professor Nav Kapur, from the University of Manchester. “We hope our study will alert clinicians, service planners and policymakers 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.”

“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,” added study leader Dr Cathy Morgan, also from the University of Manchester. “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.”

“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,” concluded co-author Carolyn Chew-Graham, GP Principal in Central Manchester and Professor of General Practice at Keele University. “We also recommend more frequent follow-up of a patient following an initial episode of self-harm.”

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