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

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      , PhD d , * , , Prof, PhD a , , PhD a , , Prof, PhD b , , Prof, MD e , , Prof, FRCPsych a , c , f , , Prof, PhD d
      The Lancet. Psychiatry
      Elsevier

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          Summary

          Background

          Self-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.

          Methods

          The 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.

          Findings

          Overall 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.

          Interpretation

          Within 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.

          Funding

          National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre.

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          Most cited references18

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          Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.

          Suicide rates are highest in late life; the majority of older adults who die by suicide have seen a primary care physician in preceding months. Depression is the strongest risk factor for late-life suicide and for suicide's precursor, suicidal ideation. To determine the effect of a primary care intervention on suicidal ideation and depression in older patients. Randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 20 primary care practices in New York City, Philadelphia, and Pittsburgh regions, May 1999 through August 2001. Two-stage, age-stratified (60-74, > or =75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. This analysis included patients with a depression diagnosis (N = 598). Treatment guidelines tailored for the elderly with care management compared with usual care. Assessment of suicidal ideation and depression severity at baseline, 4 months, 8 months, and 12 months. Rates of suicidal ideation declined faster (P =.01) in intervention patients compared with usual care patients; at 4 months, in the intervention group, raw rates of suicidal ideation declined 12.9% points (29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P =.01]). Among patients reporting suicidal ideation, resolution of ideation was faster among intervention patients (P =.03); differences peaked at 8 months (70.7% vs 43.9% resolution; P =.005). Intervention patients had a more favorable course of depression in both degree and speed of symptom reduction; group difference peaked at 4 months. The effects on depression were not significant among patients with minor depression unless suicidal ideation was present. Evidence of the intervention's effectiveness in community-based primary care with a heterogeneous sample of depressed patients introduces new challenges related to its sustainability and dissemination. The intervention's effectiveness in reducing suicidal ideation, regardless of depression severity, reinforces its role as a prevention strategy to reduce risk factors for suicide in late life.
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            A systematic review of physical illness, functional disability, and suicidal behaviour among older adults

            Objectives: To conduct a systematic review of studies that examined associations between physical illness/functional disability and suicidal behaviour (including ideation, nonfatal and fatal suicidal behaviour) among individuals aged 65 and older. Method: Articles published through November 2014 were identified through electronic searches using the ERIC, Google Scholar, PsycINFO, PubMed, and Scopus databases. Search terms used were suicid* or death wishes or deliberate self-harm. Studies about suicidal behaviour in individuals aged 65 and older with physical illness/functional disabilities were included in the review. Results: Sixty-five articles (across 61 independent samples) met inclusion criteria. Results from 59 quantitative studies conducted in four continents suggest that suicidal behaviour is associated with functional disability and numerous specific conditions including malignant diseases, neurological disorders, pain, COPD, liver disease, male genital disorders, and arthritis/arthrosis. Six qualitative studies from three continents contextualized these findings, providing insights into the subjective experiences of suicidal individuals. Implications for interventions and future research are discussed. Conclusion: Functional disability, as well as a number of specific physical illnesses, was shown to be associated with suicidal behaviour in older adults. We need to learn more about what at-risk, physically ill patients want, and need, to inform prevention efforts for older adults.
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              Open verdict v. suicide - importance to research.

              Open verdicts are often included in with suicides for research purposes and for setting health targets. To examine similarities and differences in cases defined by the coroner as suicide and open verdicts and the implications of open verdicts for suicide research. All cases of open and suicide verdicts recorded in the Newcastle Coroner's Court in the period 1985-1994 were compared on demographic and medical parameters. Open and suicide verdicts had many similarities, differing only in some respects, of which logistic regression identified the most significant to be a suicide note, method used and age. Open verdicts should be included in all suicide research after excluding cases in which suicide was unlikely. Objective criteria are needed to facilitate comparison between different studies.
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                Author and article information

                Contributors
                Journal
                Lancet Psychiatry
                Lancet Psychiatry
                The Lancet. Psychiatry
                Elsevier
                2215-0366
                2215-0374
                1 November 2018
                November 2018
                : 5
                : 11
                : 905-912
                Affiliations
                [a ]Centre for Mental Health and Safety, Faculty of Biology, Medicine and Health, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
                [b ]National Institute for Health Research (NIHR) School for Primary Care Research, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
                [c ]Centre for Suicide Prevention, Faculty of Biology, Medicine and Health, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
                [d ]Centre for Pharmacoepidemiology and Drug Safety, Faculty of Biology, Medicine and Health, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
                [e ]Research Institute, Primary Care and Health Sciences, West Midlands, Collaboration for Leadership in Applied Health Research and Care, Keele University, Staffordshire, UK
                [f ]Greater Manchester Mental Health NHS Foundation Trust, Prestwich Hospital, Prestwich, Manchester, UK
                Author notes
                [* ]Correspondence to: Dr Catharine Morgan, Faculty of Biology, Medicine and Health, Manchester Academic Health, NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester M13 9PT, UK cathy.morgan@ 123456manchester.ac.uk
                Article
                S2215-0366(18)30348-1
                10.1016/S2215-0366(18)30348-1
                6203699
                30337211
                77bfedca-3c3a-4b92-b945-f6ba9f1be8c3
                © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY NC 4.0 license

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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