From the Journals

Older adults who self-harm face increased suicide risk

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Clinical management needs to improve

The study by Morgan et al. and her colleagues reinforced both the risks of self-harm among older adults and the absence of follow-up, but more research needs to be done, according to Rebecca Mitchell, PhD, an associate professor at the Australian Institute of Health Innovation at Macquarie University in Sydney.

Just 11.7% of older adults who self-harmed were referred to a mental health specialist, even though the authors found that the older adult cohort had twice the prevalence of a previous mental illness, compared with a matched comparison cohort. Though we may not always know the factors that contributed to these incidents of self-harm, “Morgan and colleagues have provided evidence that the clinical management of older adults who self-harm needs to improve,” Dr. Mitchell wrote.

Next steps could include “qualitative studies that focus on life experiences, social connectedness, resilience, and experience of health care use,” she wrote, painting a fuller picture of the intentions behind those self-harm choices.

“Further research still needs to be done on self-harm among older adults, including the replication of Morgan and colleagues’ research 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,” Dr. Mitchell added.

These comments are adapted from an accompanying editorial (Lancet Psychiatry. 2018 Oct 15. doi: 10.1016/S2215-0366[18]30358-4). Dr. Mitchell declared no conflicts of interest.



Adults aged 65 years and older with a self-harm history are more likely to die from unnatural causes – specifically suicide – than are those who do not self-harm, according to what researchers called the first study of self-harm that exclusively focused on older adults from the perspective of primary care.

depression in the elderly: An elderly woman gazes out the window. giocalde/Thinkstock

“This work should alert policy makers and primary health care professionals to progress towards implementing preventive measures among older adults who consult with a GP,” lead author Catharine Morgan, PhD, and her coauthors, wrote in the Lancet Psychiatry.

The study, which reviewed the primary care records of 4,124 older adults in the United Kingdom with incidents of self-harm, found that older adults were infrequently referred to mental health specialists while being prescribed potentially toxic tricyclic antidepressants at a high proportion, said Dr. Morgan, of the National Institute for Health Research (NIHR) Greater Manchester (England) Patient Safety Translational Research Centre at the University of Manchester, and her coauthors. They also noted that, “compared with their peers who had not harmed themselves, adults in the self-harm cohort were an estimated 20 times more likely to die unnaturally during the first year after a self-harm episode and three or four times more likely to die unnaturally in subsequent years.”

The coauthors also found that, compared with a comparison cohort, the prevalence of a previous mental illness was twice as high among older adults who had engaged in self-harm (hazard ratio, 2.10; 95% confidence interval, 2.03-2.17). Older adults with a self-harm history also had a 20% higher prevalence of a physical illness (HR, 1.20; 95% CI, 1.17-1.23), compared with those without such a history.

Dr. Morgan and her coauthors also uncovered differing likelihoods of referral to specialists, depending on socioeconomic status of the surrounding area. Older patients in “more socially deprived localities” were less likely to be referred to mental health services. Women also were more likely than men were to be referred, highlighting “an important target for improvement across the health care system.” They also recommended avoiding tricyclics for older patients and encouraged maintaining “frequent medication reviews after self-harm.”

The coauthors noted potential limitations in their study, including reliance on clinicians who entered the primary care records and reluctance of coroners to report suicide as the cause of death in certain scenarios. However, they strongly encouraged general practitioners to intervene early and consider alternative medications when treating older patients who exhibit risk factors.

“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 behaviour and associated mortality,” they wrote.

The NIHR Greater Manchester Patient Safety Translational Research Centre funded the study. Dr. Morgan and three of her coauthors declared no conflicts of interest. Two authors reported grants from the NIHR, and one author reported grants from the Department of Health and Social Care and the Healthcare Quality Improvement Partnership.

SOURCE: Morgan C et al. Lancet Psychiatry. 2018 Oct 15. doi: 10.1016/S2215-0366(18)30348-1.

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