High Suicide Risk in Elderly Who Self-Harm

Megan Brooks

October 16, 2018

Older adults with a history of intentional self-harm are at risk of dying from unnatural causes, particularly suicide, yet they often are not referred for mental health care services, new research suggests.

Dr Nav Kapur

"As well as reminding us of the importance of self-harm in older adults, this study highlights how important self-harm is as a risk factor for suicide. We found the risk of suicide for people aged 65 years and older who had self-harmed was 145 times higher than for people of the same age who had not self-harmed," Nav Kapur, MD, professor of psychiatry and population health, University of Manchester, United Kingdom, told Medscape Medical News.

"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," Kapur added in a news release.

The study was published online October 15 in Lancet Psychiatry.

Missed Opportunity for Intervention

Using the UK Clinical Practice Research Datalink, the researchers identified 4124 people aged 65 years and older who had a documented episode of self-harm from 2001 to 2014. More than half (58%) were women.

Roughly 14% harmed themselves again within a year of the initial episode. Drug overdose was the most common form of self-harm (81%), followed by self-cutting (6%).

People older than 65 who engaged in self-harm were roughly 20 times more likely to die from unnatural causes (mostly suicide, accidental poisoning, and other accidents) during the first year afterward than individuals in an age-matched comparison cohort who had not harmed themselves (hazard ratio [HR], 19.65; 95% confidence interval [CI], 11.69 - 33.05), and the risk remained high in later years (HR, 3.41; 95% CI, 2.17 - 5.35).

The risk for death by suicide was especially high in the years after self-harm (HR, 145; 95% CI, 53.9 - 392.3).

Older adults who had harmed themselves were twice as likely to have a history of psychiatric illness (prevalence ratio, 2.10; 95% CI, 2.03 - 2.17) and were 20% more likely to experience a major physical illness, such as liver disease or heart failure (prevalence ratio, 1.20; 95% CI, 1.17 - 1.23), relative to the comparison cohort.

Among a subgroup of 2854 adults with at least 12 months' follow-up after self-harm, only 335 (12%) were referred to mental health services within that period.

Within a year of harming themselves, 59% of patients were prescribed an antidepressant, and 12% were prescribed a tricyclic antidepressant, contrary to a National Institute of Clinical Excellence (NICE) guidance that specifically recommends avoidance of tricyclic antidepressants after self-harm, the researchers note.

"Clinicians, service planners, and policy makers need to see self-harm as an opportunity to intervene. As well as managing psychiatric and physical illness, we need to attend to factors such as bereavement and social isolation, which become more common as we grow older," Kapur told Medscape Medical News.

Dementia Diagnosis

In a linked comment, Rebecca Mitchell, from the Australian Institute of Health Innovation, Macquarie University, Australia, said the study raises "questions regarding adherence to recommended clinical guidelines for the clinical management of older adults who self-harm and has signalled the need for improved quality of health care for this population."

A particularly noteworthy finding, adds Mitchell, is that among the adults who self-harmed, before the episode, dementia was more than twice as prevalent than in the comparison cohort.

"A diagnosis of dementia for some older adults can create fear of dependency, leading to depression and consideration of suicide, because individuals feel they do not want to be a burden, despite potentially having many quality years of life remaining. Recognition of the need for management of self-harm risk among older adults with dementia who retain insight, particularly in the months after initial diagnosis, is crucial," writes Mitchell.

She notes that the current findings should be replicated in studies 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."

The study was funded by the National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Center. Dr Kapur has received grants from the NIHR during the conduct of the study, as well as grants from the Department of Health and Social Care and the Healthcare Quality Improvement Partnership outside of the submitted work. He chaired the NICE self-harm guidelines, is current chair of the NICE Depression Guideline Committee, is a topic expert for the NICE suicide prevention guidelines, and is a member of the Department of Health Suicide Prevention Strategy Advisory Group. Dr Mitchell has no relevant disclosures.

Lancet Psychiatry. Published online October 15, 2018. Full text, Comment

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