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

Catharine Morgan,Roger T Webb,Matthew J Carr,Evangelos Kontopantelis,Carolyn A Chew-Graham,Nav Kapur,Darren M Ashcroft

doi:10.1016/s2215-0366(18)30348-1

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.

Highlights

Suicide is a major public health issue worldwide
Data routinely reported from the Office for National Statistics (ONS) in England and Wales indicate that suicide rates in older women have increased in the past 5 years, converging toward those of younger women of working age
In men aged 60 years and older, suicide rates have increased from 12·3 per 100 000 population in 2012 to 14·8 per 100 000 in 2015, which is higher than rates for male adolescents and younger male adults (10–29 years) at 10·6 per 100 000 in 2015.3

Summary

Introduction

Suicide is a major public health issue worldwide. With consideration of socioeconomic differences between regions, suicide risk rises with increasing age.[1,2] Data routinely reported from the Office for National Statistics (ONS) in England and Wales indicate that suicide rates in older women have increased in the past 5 years, converging toward those of younger women of working age. Non-fatal self-harm is the strongest risk factor for subsequent suicide.[4,5] Unlike other age groups, older people who self-harm have an increased suicidal intent;[6] repetition rates are low compared with middle-aged adults, self-harm is more often fatal in older adults.[5,6,7] In a UK multicentre study[4] of people with self-harm episodes presenting in hospital, suicide risk was 67 times higher among people aged 60 years and older who had harmed themselves versus their peers who had not, and was three times higher than younger individuals aged 20–59 years who had harmed themselves It is, surprising that self-harm among older people has received little attention compared with other age groups.

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