Psychiatry for the Elderly, University of Leicester, Leicester General Hospital, Leicester, UK
Psychiatry for the Elderly, University of Leicester, Leicester General Hospital, Leicester, UK
Mental Health Services for Older People, Leicestershire Partnership NHS Trust, Leicester, UK
Rehabilitation Services, Leicestershire Partnership NHS Trust, Leicester, UK
Brandon Mental Health Unit, Leicestershire Partnership NHS Trust, Leicester, UK
Correspondence: Dr M. S. Dennis, Senior Lecturer and Honorary Consultant Psychiatrist, Psychiatry for the Elderly, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK. Tel: 01162 584597; fax: 01162 731115; e-mail: msd4{at}le.ac.uk
Declaration of interest None. Funding detailed in Acknowledgements.
ABSTRACT
Summary Studying non-fatal self-harm in older adults may provide insight into suicidal behaviour in this age group. The objectives of the study were to determine clinical factors that might help to differentiate those older adults with depression who are most at risk of self-harm and suicide. We examined social factors, life events, hopelessness and other depression symptoms in a group of 48 older people with depression referred following an episode of self-harm compared with 50 similarly aged people with depression who had no history of self-harm. The groups were similar in many respects, although those in the self-harm group were more likely to have a poorly integrated social network and were more hopeless.
The study of self-harm in the elderly may provide a valuable insight into suicide. Episodes frequently involve a high degree of suicidal intent (Pierce, 1987; Merrill & Owens, 1990). As with completed suicide, there are high rates of depression in elderly people who self-harm (Pierce, 1987; Merrill & Owens, 1990), and unfortunately there are high rates of subsequent suicide, in particular in those with persistent depression (Hepple & Quinton, 1997).
METHOD
Self-harm group
Seventy-six adults aged 65 years and over who had self-harmed were
prospectively studied. They were identified as referrals to the local
specialist self-harm team. Written informed consent was obtained from the
participant and the following scales were then administered: the Beck
Depression Inventory (BDI; Beck &
Steer, 1993a), the Beck Hopelessness Scale (BHS;
Beck & Steer,
1993b), the Suicide Intent Scale (SIS;
Beck et al, 1974) and
the 15-item Geriatric Depression Scale (GDS-15;
Sheikh & Yesavage, 1986).
The research psychiatrist then interviewed participants in a semi-structured
manner; 48 of the 70 participants seen by the psychiatrist were diagnosed as
having a depressive episode according to ICD-10 criteria (F31-33;
World Health Organization,
1992). Levels of social support were also assessed using an
instrument designed specifically for the study, the Social Contact Schedule
(SCS; further details available from the author upon request). A social
network type (Wenger, 1997)
was determined from the information obtained from the clinical history, the
SCS and the subsequent Life Events and Difficulties interview. Participants
were asked to rate their satisfaction with the level of support they were
receiving from the statutory and voluntary agencies, and from family and
friends, on a visual analogue scale. At further interview environmental
effects for the 6 months prior to the index episode of self-harm were studied
by means of the Life Events and Difficulties Schedule (LEDS-2;
Bifulco et al, 1989).
All life events and difficulties reported by the participants in the self-harm
group were rated at consensus meetings.
Comparison group
The comparison group consisted of 50 persons aged 65 years or over referred
to their local community mental health team for the elderly with an ICD-10
diagnosis of depressive episode (F31-33). Exclusion criteria for this group
were a previous episode of self-harm, inability to speak English or a
Mini-Mental State Examination (MMSE;
Folstein et al, 1975)
score <24. The assessment process was similar to that in the self-harm
group, but the reference point for life events was 6 months prior to onset of
the current depressive episode.
Statistical analysis
Analyses were performed using the Statistical Package for the Social
Sciences, version 10 for Windows. Demographic details, risk factors and
categorical data are expressed as percentages within groups, and compared with
the Pearson chi-squared test (two-tailed) or Fisher's exact test if
appropriate. Interval data (rating instruments) and ordinal data were analysed
non-parametrically throughout with the Mann-Whitney U-test. The
results for statistical tests were regarded as significant at or below the 5%
probability level.
RESULTS
The median SIS score in the self-harm group was 16 (interquartile range 11-20). Two-thirds (66%) of people in this group scored 14 or more, indicating significant suicidal intent, and in 32 cases (67%) the researcher felt that the participant had wished to die at the time of their self-harm episode. Table 1 compares the main variables in the two study groups.
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A similar proportion of participants had first-episode depression compared
with recurrent depression or bipolar affective disorder in both the control
group (29 out of 50) and the self-harm group (30 out of 48); Pearson
2=0.2, d.f.=1, P=0.65. There was no significant
difference for the majority of questions of the GDS-15 between the groups,
except that participants in the self-harm group were much more likely to
respond yes to the question Do you feel your situation is
hopeless? (
2=7.3, d.f.=1, P=0.007) and
no to the question Do you think it is wonderful to be
alive now? (
2=3.8, d.f.=1, P=0.05). On the
BDI, participants in the self-harm group were more likely to score higher on
thoughts of suicide and self-harm than the control group
(
2=11.6, d.f.=3, P=0.009) and rate themselves as more
sad (
2=1.5, d.f.=3, P=0.04), but were less likely to
cry (
2=9.2, d.f.=3, P=0.03) than the controls.
DISCUSSION
This study has important service and clinical implications for older people. First, the high rate of suicidal intent among older people with depression who have self-harmed emphasises the importance of such individuals receiving a skilled and detailed assessment of both risk and need. This has been recognised in the recently circulated National Institute for Clinical Excellence (2004) guidelines on the hospital management of self-harm, which recommend that older people treated for self-harm should be seen by mental health professionals who are skilled in the assessment of this group of patients and in recognising depression in later life.
Second, there are important implications for the care of elderly people with depression in both primary and secondary care settings. The importance of asking directly about thoughts of self-harm and tedium vitae is given emphasis by the similarities in clinical profiles between the groups. Hopelessness is an important discriminator for those at high risk. Unfortunately, there are some questions in the full Beck Hopelessness Scale that are inappropriate for a very elderly population, and the abbreviated ten-item version of the scale has better face validity for older people.
The comparison between our two groups of people with depression gives emphasis to Durkheim's observations on social integration (Durkheim, 1951; first published 1897). Those in the self-harm group were more likely to have a poorly integrated social network than the controls. Loneliness, lack of support from services and poor integration in the community therefore appear to be important factors in determining suicidal behaviour in older adults. Both groups had similar rates of severe independent life events, and the rate of approximately 40% in each group experiencing severe life events during the 6-month study period is comparable with other UK studies (Murphy, 1982; Lam et al, 1987; Evans & Katona, 1993). Life events are important therefore in the aetiology of depression and self-harm, but there was no excess of events in the self-harm group compared with the control group. Life events do not act alone as precipitating factors for self-harm in elderly people with depression, although they may act as precipitating factors in particularly predisposed individuals. Their role in interaction with other factors, in particular social support, appears to be influential.
ACKNOWLEDGMENTS
We thank the self-harm team and community mental health teams of the Leicestershire Partnership NHS Trust for their help in recruiting patients, Nicky Spiers for statistical advice, and Research into Ageing and Help the Aged for their financial support to the project.
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Received for publication January 12, 2004. Revision received September 16, 2004. Accepted for publication September 29, 2004.