In the Journals

Older adults who self-harm at higher risk for unnatural death

In the first year after self-harm, only about 12% of older adults were referred by a primary care physician to mental health services, according to data published in The Lancet Psychiatry.

The researchers also reported that older adults were at higher risk for unnatural death after self-harm, particularly of suicide, compared with those without a history of self-harm.

“Self-harm among older people has received little attention compared with other age groups,” Catharine Morgan, PhD, from The University of Manchester, and colleagues wrote.

“In England, the National Institute for Health and Care Excellence (NICE) clinical guidance recommends that older adults are assessed by an old-age psychiatrist or mental health specialist after a self-harm episode because of raised levels of suicidal intent at older age,” they continued. “However, previous studies of self-harm in older people often do not have detail on specific clinical management after the index episode.”

The investigators examined the incidence of self-harm, later clinical management, prevalence of mental and physical diagnoses before and after self-harm, and unnatural-cause mortality risk in a primary care cohort of 4,124 adults aged 65 years and older with a self-harm episode recorded between 2001 and 2014.

Researchers assessed patient data recorded in the U.K. Clinical Practice Research Datalink, which contains electronic patient records from general practices that describe routine clinical data from primary and secondary care services to calculate standardized incidence of self-harm. They also evaluated the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm in 2,854 adults followed for at least 1 year.

Over the 13-year period, Morgan and colleagues found that the overall incidence of self-harm in older adults was 4.1 per 10,000 person-years. After self-harm, analysis revealed that 11.7% of older adults were referred to psychiatric services, 59.3% received prescription for an antidepressant and 11.8% received prescription for a tricyclic antidepressant. Women received more referrals than men and more often received psychotropic medication.

In total, 2,454 older adults were in the linked self-harm cohort and 48,921 were in the matched comparison cohort. Previous mental illness diagnosis was more than twice as prevalent among participants with history of self-harm than among comparison participants (prevalence ratio = 2.1; 95% CI, 2.03-2.17), as was a later diagnosis of mental illness (prevalence ratio = 2.18; 95% CI, 2.06-2.32). In addition, the prevalence of prior diagnosis of a physical health condition was 20% higher in the self-harm cohort (prevalence ratio = 1.2; 95% CI, 1.17-1.23).

Older adults in the self-harm cohort were about 20 times more likely to die from unnatural causes during the first year after a self-harm episode than those who had not harmed themselves (HR = 19.65; 95% CI, 11.69-33.05) and almost four times more likely to die unnaturally in subsequent years (HR = 3.41; 95% CI, 2.17-5.35). Moreover, the risk for death by suicide increased substantially in the self-harm cohort (HR = 145.4; 95% CI, 53.9-392.3).

“Primary health care professionals have the opportunity to intervene since older adults are reported to consult more frequently than younger adults because of their complex needs and potentially higher levels of psychiatric and physical multimorbidity,” Morgan and colleagues wrote. “Health care professionals should take the opportunity to consider the risk of self-harm when an older person consults with other health problems, especially when major physical illnesses and psychopathology are both present, to reduce the risk of an escalation in self-harming behavior and associated mortality.”

Further research of self-harm with the use of primary care records is warranted, Rebecca Mitchell, MD, of Macquarie University in Australia, wrote in a related editorial.

“This study has raised questions regarding adherence to recommended clinical guidelines for the clinical management of older adults who self-harm and has signaled the need for improved quality of health care for this population,” Mitchell wrote.

Disclosure s : Morgan reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Mitchell reports no relevant financial disclosures.

In the first year after self-harm, only about 12% of older adults were referred by a primary care physician to mental health services, according to data published in The Lancet Psychiatry.

The researchers also reported that older adults were at higher risk for unnatural death after self-harm, particularly of suicide, compared with those without a history of self-harm.

“Self-harm among older people has received little attention compared with other age groups,” Catharine Morgan, PhD, from The University of Manchester, and colleagues wrote.

“In England, the National Institute for Health and Care Excellence (NICE) clinical guidance recommends that older adults are assessed by an old-age psychiatrist or mental health specialist after a self-harm episode because of raised levels of suicidal intent at older age,” they continued. “However, previous studies of self-harm in older people often do not have detail on specific clinical management after the index episode.”

The investigators examined the incidence of self-harm, later clinical management, prevalence of mental and physical diagnoses before and after self-harm, and unnatural-cause mortality risk in a primary care cohort of 4,124 adults aged 65 years and older with a self-harm episode recorded between 2001 and 2014.

Researchers assessed patient data recorded in the U.K. Clinical Practice Research Datalink, which contains electronic patient records from general practices that describe routine clinical data from primary and secondary care services to calculate standardized incidence of self-harm. They also evaluated the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm in 2,854 adults followed for at least 1 year.

Over the 13-year period, Morgan and colleagues found that the overall incidence of self-harm in older adults was 4.1 per 10,000 person-years. After self-harm, analysis revealed that 11.7% of older adults were referred to psychiatric services, 59.3% received prescription for an antidepressant and 11.8% received prescription for a tricyclic antidepressant. Women received more referrals than men and more often received psychotropic medication.

In total, 2,454 older adults were in the linked self-harm cohort and 48,921 were in the matched comparison cohort. Previous mental illness diagnosis was more than twice as prevalent among participants with history of self-harm than among comparison participants (prevalence ratio = 2.1; 95% CI, 2.03-2.17), as was a later diagnosis of mental illness (prevalence ratio = 2.18; 95% CI, 2.06-2.32). In addition, the prevalence of prior diagnosis of a physical health condition was 20% higher in the self-harm cohort (prevalence ratio = 1.2; 95% CI, 1.17-1.23).

Older adults in the self-harm cohort were about 20 times more likely to die from unnatural causes during the first year after a self-harm episode than those who had not harmed themselves (HR = 19.65; 95% CI, 11.69-33.05) and almost four times more likely to die unnaturally in subsequent years (HR = 3.41; 95% CI, 2.17-5.35). Moreover, the risk for death by suicide increased substantially in the self-harm cohort (HR = 145.4; 95% CI, 53.9-392.3).

“Primary health care professionals have the opportunity to intervene since older adults are reported to consult more frequently than younger adults because of their complex needs and potentially higher levels of psychiatric and physical multimorbidity,” Morgan and colleagues wrote. “Health care professionals should take the opportunity to consider the risk of self-harm when an older person consults with other health problems, especially when major physical illnesses and psychopathology are both present, to reduce the risk of an escalation in self-harming behavior and associated mortality.”

Further research of self-harm with the use of primary care records is warranted, Rebecca Mitchell, MD, of Macquarie University in Australia, wrote in a related editorial.

“This study has raised questions regarding adherence to recommended clinical guidelines for the clinical management of older adults who self-harm and has signaled the need for improved quality of health care for this population,” Mitchell wrote.

Disclosure s : Morgan reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Mitchell reports no relevant financial disclosures.