Older people who self harm need long term follow-up to reduce suicide risk

BMJ 2012; 344 doi: (Published 01 May 2012) Cite this as: BMJ 2012;344:e3120
  1. Zosia Kmietowicz
  1. 1London

Older people who harm themselves are at a much greater risk of suicide than are people of the same age in the general population and three times as likely to take their own life than are younger people who self harm, a study has found.

The findings point to the need for hospitals to adhere to existing guidance on the treatment of older people who self harm and not to discharge patients from the emergency department before they have been assessed by a mental health specialist trained to assess the risks and needs in this age group, says an accompanying editorial.

Researchers from the University of Manchester followed 1177 people over the age of 60 years who were admitted to six general hospitals in Oxford, Manchester, and Derby after self harming between 2000 and 2007. They found that the most common method of self harm was poisoning (88%), followed by injury, including cutting (9%), and other violent methods such as hanging or asphyxiation (3%) (British Journal of Psychiatry 2012;200:399-404, doi:10.1192/bjp.bp.111.094177).

One in eight (12.5%) of these 1177 people harmed themselves again within 12 months, and 1.5% had died by suicide within 12 months. The risk of suicide was 67 times the risk among adults in the general over-60s population and three times the risk of suicide among younger adults who self harm. The suicide rate was highest among men aged 75 years or older. Those who repeatedly harmed themselves were more likely to be single or to live alone. Other important risk factors included previous self harm and contact with mental health services.

Elizabeth Murphy, of the Centre for Mental Health and Risk at the University of Manchester and who led the study, said, “All older adults who present to hospital with self harm should be considered as being at elevated risk of suicide, unless a detailed assessment shows otherwise. In particular, men over 75 years old need to be carefully monitored and assessed, as the risk of suicide is particularly increased in this group.”

In the editorial Michael Dennis, professor in old age liaison psychiatry at Swansea University, and David Owens, senior lecturer in psychiatry at the University of Leeds, say that healthcare providers should monitor and audit their implementation of guidelines from the National Institute for Health and Clinical Excellence and from the Royal College of Psychiatrists on the management of self harm, particularly where there is pressure on beds (British Journal of Psychiatry 2012;200;356-8, doi:10.1192/bjp.bp.111.104109).

In the present study over half (55%) of the participants received specialist mental health care after the episode of self harm. However, the editorialists point out that in previous studies two thirds of patients were still receiving psychiatric treatment a year after the incident.

“The current research base therefore points to the need for assessment of suicidal ideation as a continuous process during an episode of care: during the course of a depressive episode older patients can change from being ‘passive ideators’ with death wishes to having active suicidal thoughts.”

They add, “When striving to reduce the risk of subsequent suicide in individuals who have self-harmed, attending only to the clinical management of late-life depression is unlikely to be sufficient. In the social domain, integration and support are particularly relevant: self-harm in older people is associated with widowhood, living alone, social isolation and low levels of social support.”


Cite this as: BMJ 2012;344:e3120