INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 2: 105-1 10 (1987)

DELIBERATE SELF-HARM IN THE ELDERLY DAVID PIERCE

Consultant Psychiatrist, East Glamorgan Hospital, Pontypridd, Mid Glamorgan, U K

SUMMARY

This article reviews 145 patients over the age of 65 years seen at a district general hospital after deliberate self-harm between 1973 and 1985. There was no significant change in the numbers seen per year, and they comprised 5.4% of all the hospital’s self-harm cases. The male to female ratio was 1:1.5 although the self-harm rates for males and females over 65 in the local population were identical. Fifty-five per cent widowed, over 90% of the patients had depressive conditions, only 3% had an established dementia, and 63% had significant physical illness. Half the patients received inpatient psychiatric treatment. Under 10% of the patients gave a history of earlier self-harm, while both the repetition and suicide rates were very low. These findings are discussed.

KEY wom-At tempted suicide, self harm, suicide intent, patients aged over 65.

INTRODUCTION

The pattern of behaviour now described as non-fatal deliberate self-harm (DSH), para- suicide or simply attempted suicide is seen most often in young people, unlike completed suicide which is commonest among the elderly (Office of Health Economics, 1981). At the same time it is acknowledged that an overlap exists between populations of those who attempt and those who commit suicide (Ovenstone and Kreitman, 1974). It is known that suicide intent measured after DSH is particularly high in the old (Pierce, 1977) and that high intent bears some relation to eventual suicide (Pierce, 1981). Detailed study of people who kill themselves has shown that many have been suffering from treatable depressive illnesses (Barraclough et a l . , 1974) and such illnesses are very common in old age when, unfortunately, they do not respond well to treatment (Murphy, 1983). These considerations relating DSH among the elderly both to depress- ion and to suicide suggest that study of the behaviour pattern in this age group should not be neglected, even though the relatively small number of cases makes such study difficult.

Since earlier reports of suicidal behaviour in the elderly (e.g. Batchelor and Napier, 1953; O’Neill et al., 1965), new instruments for studying the subject have been developed (Pallis et a l . , 1982). The opportunity to review a substantial series of DSH patients of advanced years using

scales related to suicidal behaviour has arisen recently, since records of all DSH cases seen at East Glamorgan Hospital have been kept for the past 13 years.

The overall objective of the review is to set the problem of DSH in the elderly in the context of the current phenomenon of DSH as a whole.

Its more specific aims are:

1. To report the proportion of DSH cases who were over the age of 65;

2. To report any changes in the numbers of DSH patients in this age group presenting each year over the last decade;

3. To describe their characteristics; 4. To measure aspects of their suicidal intent;

and 5. To find out how many of them repeated their

self-harming behaviour, either fatally or non- fatally.

METHOD

Cases of DSH occurring within the East Glamor- gan Health District (population 180,000) and presenting to the medical services are referred to East Glamorgan General Hospital. All such patients attending the hospital are interviewed as soon as their clinical condition allows, and all those aged 65 years or over at the time of the DSH episode that led to their hospital treatment

088S-623O/87/02O105-06$05 .OO 0 1987 by John Wiley CG Sons. Ltd.

Received 20 August 1986 Accepted 12 February I987

D. PIERCE 106

50.

40. Number

of cases

30.

2 0 .

10.

between the years 1973 and 1985 were included in this review. All these elderly patients were admitted to the medical or surgical wards of the hospital after emergency treatment in the casualty department, and their interviews took place in small examination rooms off the wards. Most of the interviews were carried out by the author, but a small number (4%) were undertaken by psychiatric trainees who had previously been instructed in the interviewing technique.

The interview was semistructured: first basic demographic data were noted, then the patient was encouraged to give his own account of events leading to admission. Specific questions then led to the completion of suicide intent scores using both the Beck scale (Beck et al. , 1974) and the IS scale (Pierce, 1977). These scales consist of series of items, scored by the interviewer, based on replies to questions dealing first with the objec- tive circumstances of the episode, such as degree of isolation at the time or of preparation beforehand, secondly with the patient’s self- report as to his state of mind at the time, and finally with the medical risk attached to his actions. Their satisfactory reliability has been previously reported (Beck et al. , 1974; Pierce, 1977).

The interview then led to the formulation of a psychiatric diagnosis, based on the history of the present condition and the clinical state on examination. The criteria for the diagnosis of depressive illness were those used in the MRC trial of maintenance treatment for depression (Mindham et al . , 1973). Other conditions were classified using the ICD 9 system.

Note was taken of the presence of significant physical illness: this was defined as an illness lasting for more than two weeks which required treatment and which substantially interfered with the patient’s well-being or with his ability to care for himself. The patient’s view was elicited as to whether any physical illness present had contri- buted to the self-harm, for instance on account of pain.

A decision was then taken about further management, classified as: 1. Admission for psychiatric treatment; 2. Discharged to attend a psychiatric outpatient

clinic; or 3. Discharged to care of general practitioner.

Repeat episdoes of non-fatal self-harm present- ing at the hospital were recorded by the author or

-

.

.

~

by trainee psychiatric staff as they occurred. Self-reported episodes without any objective confirmation of treatment were ignored both at initial interview and during the follow-up period. Postmortem and coroners’ reports were examined when the study was being written up to identify any suicides that had taken place.

RESULTS

During the years 1973-1985 145 patients over the age of 65 years attended the hospital for treatment of the effects of DSH. They made up 5.4% of the total number of self-harm patients seen at the hospital during that time. They comprised 58 men and 87 women, giving a male to female ratio of 1:1.5. Eighty were widowed, 59 married or cohabiting, six divorced or separated and only five were single; 44 lived alone.

The mean age of these elderly patients was 72 k 5.5 years, and their age distribution is given in Fig. 1, which shows a sharp fall in the number of cases at around the age of 75 years.

Although the number of cases aged 65 years and over seen per year varied widely (from three to 19), there was no evidence of any particular trend in the change in annual numbers between

1 65-68 69-72 73-76 77-80 81-84 85-88 89-92

Age

Fig. 1. Age distribution, DSH patients over 65

DELIBERATE SELF-HARM 107

1973 and 1985. The mean number per year for the 13 years as a whole was 11, while the number seen per year between 1973 and 1975 was 14 and the corresponding number for the pears 1983-1985 was 16. The mean rate for DSH in the local population aged 65 years and over was calculated using population tables for the health districts concerned, and was found to be 46 per 100,000 per year.

The method employed was a drug overdose in 95% of cases. The drugs used included a large variety of minor tranquillizers, hypnotics, anti- depressants and analgesics. Occasionally other drugs such as antibiotics were taken and in many cases many more than one drug was ingested. Barbiturates were used in only six cases in the mid nineteen seventies. The other 5% of cases included wrist and throat cutting, suffocation and hanging. A few patients used more than one method in one episode.

Suicide intent measurements gave a mean Beck scale intent score of 12.18f5-82 for all the patients over 65 years (range 0-26). The mean score for females was 11.4 f 5.72 while that for males was 13.1 k 5.65. The difference between these scores was significant at a level of p < 0-05 (unpaired t-test). Using the IS scale the intent scores were 10.15 f 5-21 for all patients over 65 (range 0-23), 9.5 f 5.25 for the women and 11.2 k 4.86 for the men. The difference between the scores for the two sexes here only reached a significance level of 0.1 > p > 0.05 (upaired t- test). When cases of very high intent (> 20 on the Beck scale) were compared with very low intent cases (<5 on the Beck scale) the high intent group contained a greater proportion of men (50%) than the low intent group (29%). The mean age of the high intent patients was 72-78f5.37 while that for the low intent cases was significantly lower at 69-47 f 3.74 (p < 0.05).

The level of suicidal intent was reflected in the decisions made regarding patient management. The mean Beck intent score of those patients admitted for psychiatric treatment was 12.97 f 5.98, while for all those not admitted for such treatment the mean was lower at 11.39 +. 5.69. The differences between these scores were not, however, significant. Patients referred direct to their general practitioners received considerably lower intent scores (9.54 f 5-55) on the Beck scale, and these scores were significantly different (p < 0.01) from those given to the patients who were admitted for psychiatric treatment.

Diagnostic assessment revealed an overwhelm- ing predominance of depressive conditions (93%); in 39 of these 135 cases the depression was felt to be secondary to problems such as physical ill-health, housing or financial stress. Relatively few patients (13%) showed psychotic symptoms. The number of patients suffering from an established dementia was very small indeed (four cases or 2.8%), as was the number who harmed themselves during the course of an acute con- fusional state (three cases or 2.1%). Three patients showed evidence of marked personality disorder while 18 were dependent on alcohol, although this dependence had not necessarily contributed to their self-harm.

As expected, a large proportion of the patients (63%) were found to be suffering from significant physical illnesses, and in 18% it was felt, on the basis of the patients’ statements about the factors leading to the episode, that physical illness had contributed to the self-harm, usually on account of pain or of general demoralization about declining health.

As far as immediate management was con- cerned 70 patients, or nearly half the total, were admitted for inpatient psychiatric treatment after they had recovered from the effects of their self-harm. Nearly all these were treated for depressive conditions but many of course needed treatment for incidental physical illnesses. Thirty- seven patients were treated at a psychiatric outpatient clinic after discharge from the medical wards. One third of the patients received social work advice at some stage. Only one patient left hospital prematurely against advice, and the great majority of patients given outpatient appoint- ments did attend, usually accompanied by rela- tives.

Only 10 patients gave a history of earlier episodes of DSH, and during the very variable follow-up periods ranging from one to 12 years only 12 patients (8.3%) repeated non-fatally while four patients committed suicide (2.8%). Further analysis of these repeats showed that the mean interval between index episode and the first non-fatal repeat was 12 months (range 3-31). All non-fatal repetitions except one occurred within an interval of 31 months. The mean interval between index episode and suicide was 24 months (range 1-39). The Beck intent scores for patients who later committed suicide were very much higher (18.25 f 4.16, p < 0.001) than those for the others.

108 D. PIERCE

DISCUSSION

The proportion of DSH cases who were aged 65 years and over, reported here as one in 20, agrees closely with the 4.8% recorded by Morgan et al. (1975), and is compatible with Kreitman’s report of 11% of a series of Edinburgh ‘first ever’ cases as being over the age of 60 (Kreitman, 1977). This implies that the elderly patients included in the present study are likely to be typical for the country as a whole. This 5% of cases occurred in 18% of the ‘at risk’ population, i.e. all persons over the age of 15. These figures led to an overall risk of self-harm for anyone over the age of 65 that amounted to one quarter of the risk for a person between 15 and 65 years of age.

The male to female ratio of 1:1.5 compares with 1:2 given by Morgan et al . (1975) for unselected cases, which is typical of most such series. Kreitman (1977) described a 1969 cohort of patients which contained cases over the age of 55 also with a sex ratio of 1:2. The present study demonstrated no real preponderance of female cases; when the population structure of the hospital catchment area was taken into account the DSH rates for men and women aged 65 and over became identical. This is of course in sharp contrast to the differing rates for the sexes among younger DSH cases (Kreitman, 1977).

The age distribution of the sample suggests that very few old people indeed resort to non-fatal DSH after the age of 75. It was felt that the number of patients included in the study was not large enough to allow a satisfactory comparison with the age distribution of the general popula- tion, but it may well be possible to comment further on this point at a later date when more patients have been studied.

Do the results point to the stresses which might contribute to self-harm in these men and women? Some findings reflected the particular importance of social isolation among elderly DSH patients: 55% were widowed, compared with 41% of the local over-65 population as a whole, while 30% of the patients lived alone. Only 10.1% of un- selected DSH patients of all ages live alone (Morgan et a l . , 1975). It is hoped to study this aspect of the problem further by obtaining data as to how long the patients had been living alone and how they had been affected by this situation.

The diagnostic findings contrast completely with those derived from unselected consecutive samples of DSH patients attending hospital.

These contain large proportions of cases both of personality disorder and alcohol abuse, with fewer depressives (e.g. Silver et al . , 1971). The number of patients suffering from established organic dementia was low compared with some earlier reports (O’Neill et al., 1965; Batchelor and Napier, 1953; Sendbuehler and Goldstein, 1977). The last paper in particular reported a high proportion (53%) of patients with organic brain disease, but most of Sendbuehler and Goldstein’s cases used methods other than overdoses, 30% were psychotic, and there can be no doubt that the patients in the present study were strikingly different to theirs. It seems likely that overdose cases were excluded from their series and were treated by other medical services.

The few cases of organic brain disease in the present study were of clinical importance as the patients, who were both confused and depressed, tended to make impulsive yet very hazardous attempts on their lives, probably accompanied by cerebral disinhibition, and sometimes using more than one method of self-injury. This contrasts with comments made by Sendbuehler and Gold- stein that patients with organic disease tend to make unsuccessful suicide bids because of poor coordination and lack of planning. The 5% of patients who used methods other than drug overdosage to harm themselves were most often severely depressed, and the injuries inflicted on the body were serious and mutilating in the majority of cases.

The repetition rate for these elderly patients was a good deal lower than that generally reported for unselected samples (e.g. Kessel and McCulloch, 1966), sometimes in the range of 20-30% per year. It is very unlikely that repeat episodes were missed, as most patients were under psychiatric supervision and they were not likely to move out of the hospital catchment area. The low rate may reflect the absence of clinical factors known to be associated with repetition such as personality disorder and alcohol abuse.

For patients under 65 years of age living in the same area the repetition rate is considerably higher, namely 18% per annum in the two years after the first episode. It was pointed out earlier that most of the repetitions in the present study occurred within three years; when the follow-up period was limited to two years the repetition rate for those two years was found to be 4% per annum.

Only 7% of the patients gave a history of DSH

DELIBERATE SELF-HARM 109

episodes earlier in life. This contrasts with about half of unselected DSH cases (Bancroft and Marsack, 1977; Morgan et al., 1975) and with a figure of 30% reported by Sendbuehler and Goldstein (1977) for a series of patients over the age of 60 years - as pointed out already, however, their patients were very different from those included in the present study. The rarity of previous episodes may imply that DSH was unacceptable socially when these patients were young, or that they had only acquired the capacity to harm themselves under stress when they grew old. It is of interest that 30% of the patients had received treatment for depressive illnesses in the past, but these earlier illnesses had not usually led to self-harm.

Both the Beck and IS scale suicide intent scores for the elderly patients were much higher than those previously reported for unselected groups of DSH cases of all ages (p < 0-OOl), confirming earlier reports of high intent in the older patient (Pierce, 1977).

The very low suicide rate at follow-up is currently the subject of further study. High intent scores among the elderly patients would suggest a high rate for subsequent suicide, probably well above the 1-2% reported for unselected DSH cases per year. The first possible explanation for the low rate is of course that cases of suicide were missed, but this seems unlikely as local coroners’ and postmortem records have been examined. The next contributory factor could be that patients have died within the follow-up period from natural causes. Work is therefore now under way to trace all patients and establish the cause of death for those who have died. A third and more hopeful explanation is that the patients have been successfully treated for depressive illnesses which have not recurred. This seems improbable in view of the poor response reported by Murphy (1983) for depressive disorders in old age.

The limitations of the study lie partly in the very variable follow-up period, and in the absence of information at present as to how many patients have died from natural causes during that period. In addition it is not known how many patients of 65 years and over living in the same area might have been treated at home for the effects of self-harm. It is of course probable that such patients would not have been severely depressed and that they would have made fairly minor attempts to harm themselves.

ACKNOWLEDGEMENT

The author wishes to thank Robert Newcombe of the Department of Medical Statistics, University Hospital of Wales, Cardiff for help with statistical analysis.

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