“We have identified a group at high risk of premature unnatural death and identified areas of improvement for clinical management of older-aged adults in primary care,” wrote Catherine Morgan, M.D., of the University of Manchester, U.K., and colleagues. “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. “
Morgan and colleagues analyzed data from the UK Clinical Practice Research Datalink, which contains anonymous patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. They identified 4,124 adults aged 65 years and older with a self-harm episode recorded during calendar years 2001 to 2014. Of these episodes, 3,327 (80.7%) involved ingestion of drugs and 234 (5.7%) involved self-cutting.
For their analysis, the researchers focused on the 2,854 adults with at least 12 months of follow-up data. They examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. They compared the self-harm cohort with a group of similarly aged patients who did not engage in self-harm.
Within 12 months of their initial self-harm episode, just 335 (11.7%) of 2,854 older adults were referred to mental health services, 1,692 (59.3%) were prescribed an antidepressant, and, of these, 336 (11.8%) received a tricyclic antidepressant, which can be fatal when taken in overdose.
In the year after the first self-harm episode, 412 (14.4%) individuals had another self-harm episode, of whom 344 (83.5%) had one repeat episode and 68 (16.5%) had two or more episodes. A total of 908 (37.0%) deaths occurred in the self-harm cohort compared with 12,683 (25.9%) deaths in the comparison cohort, of which 54 (5.9%) were unnatural deaths and 36 (4.0%) were deaths by suicide in the self-harm cohort versus 275 (2.2%) unnatural deaths and 12 (<0.1%) deaths by suicide in the comparison cohort, the authors reported.
“After self-harm in an older adult, improvement of referral rates [to specialty mental health care] and consideration of possible alternative medication, with particular avoidance of TCAs [tricyclic antidepressants], might reduce the risk of escalating self-harm behavior and associated mortality risk,” the authors wrote.
For related information, see the American Journal of Psychiatry article “Suicide Following Deliberate Self-Harm.”