Self-harm in older people: incidence, clinical management and mortality risk
Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death.
The Lancet Psychiatry
Morgan C, Webb RT, Carr MJ, Kontopantelis E, Chew-Graham CA, Kapur N, Ashcroft DM.
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.
Self-harm is a major risk factor for suicide, with older adults having reportedly greater suicidal intent than any other age group.
With the aging population rising and lack of research focus in this age group, 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 in a primary care group of older adults.
The UK Clinical Practice Research Datalink contains anonymised patient records from general practice that routinely capture clinical information from primary and some secondary care services.
Standardised incidence was estimated and in 2854 adults with at least 12 months follow-up, frequency of psychiatric referrals and prescription of psychotropic medication after self-harm was investigated.
We estimated prevalence of mental and physical illness diagnoses before and after self-harm and examined risk of mortality.
4,124 adults aged 65 years and older with a self-harm episode were recorded during 2001-14.
After self-harm, 335 (11.7%) of 2,854 adults were referred to mental health services, 1,692 (59.3%) were prescribed an antidepressant, and 336 (11.8%) were prescribed a tricyclic antidepressant (TCA).
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, and there was an increased risk of suicide of 145 times (hazard ratio 145·4 [95% CI 53·9–392·3]).
Within primary care, we have identified a group of older adults at high risk from an unnatural death, particularly within the first year of self-harm. We have highlighted a high frequency of prescription of TCAs, known to be dangerous 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.
- People over 65 who self-harm are 20 times more likely to die an unnatural death and 145 times more likely to die by suicide than people of the same age who had not self-harmed.
- Only 12% of older patients who self-harmed had a record of being referred to a mental health service for aftercare.
- Physical health problems were more common in older patients who had harmed themselves compared to those who had not.
- Following a self-harm episode, over one in ten were prescribed tricyclic antidepressants which can be toxic when taken in overdose.
- There is a need for earlier intervention, careful alternative prescribing and better support for older people following an episode of self-harm.
This study was funded by the National Institute for Health Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, grant number PSTRC-20160-03. The views expressed are those of the authors and not necessarily those of the National Health Service (NHS), the NIHR, or the Department of Health and Social Care.
This study is based in part on data from the Clinical Practice Research Datalink (CPRD) obtained under licence from the UK Medicines and Healthcare products Regulatory Agency. The data is provided by patients and collected by the NHS as part of their care and support.
The Office for National Statistics (ONS) is the provider of the ONS data contained within the CPRD data. Hospital Episode Data and the ONS Data Copyright (2014) are reused with the permission of The Health and Social Care Information Centre.
All rights reserved. The study was approved by the independent scientific advisory committee CPRD research (protocol number 13_122ARAMn). The interpretation and conclusions contained in this study are those of the authors alone. We would also like to acknowledge the contribution of our Patient and Public Involvement partners and their suggestion of extending our self-harm investigations among adults aged 65 years and over from an earlier study.