Study sheds fresh light on self-harming in later life

A “one-size fits all” approach to suicide prevention will not work. We especially need new strategies tailored to the unique circumstances of older people, says a University of Auckland researcher.
Dr Gary Cheung, from the university’s Faculty of Medical and Health Sciences, led a study published in the New Zealand Medical Journal that reveals a distinctly different pattern of stressors and behaviours in middle-aged and older people who self-harm and make suicide attempts.

Physical illnesses and depression were common factors associated with self-harm and attempted suicide in older people, while the stressors of relationship separation and financial trouble featured more strongly in middle-aged people, the study showed.

Dr Cheung, a psychiatrist and senior lecturer, hopes the findings will help policymakers and health workers develop age-group-targeted screening and treatment to prevent mid-life and late-life suicides.

The study – the first of its kind in New Zealand - came out of research Dr Cheung completed for his PhD on suicide in older New Zealanders, a topic that had received little scrutiny despite the high rates in ageing men. Ministry of Health figures from 2008-2017 show that male suicide rates start climbing from age 65, peaking at 32 per 100,000 in men aged 85 and over. For men aged 45-49, the rate was 24 per 100,000. (In women, the suicide rate peaked at 11 per 100,000 in ages 15-20 years.)

“As the baby boomers age, the issue of suicide and suicidal behaviours in later life will become even more pressing,” says Dr Cheung.

A history of self-harm is a strong predictor for future suicide. So Dr Cheung and co-researcher Dr Yu Mwee Tan analysed patient records of middle-aged (45-64 years) and older (65-plus) men and women who visited the emergency department of Middlemore Hospital, Auckland for self-harming from 2010-2013. They defined self-harm as ‘the direct, deliberate act of hurting or injuring the body…without necessarily wanting to die, as in suicide attempt’.

They identified 420 people who made 569 self-harm attempts in the three-year period. Most – 379 – were in the middle-age group, of whom more (57 percent) were female. But in the older group, more were men (61 percent).

Quite a different picture emerged for each age group. Key findings included:

• The older-aged group was more likely to report physical illness as a stressor, have a history of depression and be diagnosed with depression (52 percent) at the time of their self-harming.
• The middle-aged group was more likely to report relationship separation and financial trouble as stressors.
• Older people who self-harmed were more likely to do so with suicidal intent compared to the middle-aged group, and their suicide attempts were more likely to be fatal, and more likely (82 percent) to happen at home.
• A third (33 percent) of middle-aged people who self-harmed had a positive blood alcohol level.
• Older-aged people were less often tested for blood alcohol level, even though those who were tested had the same blood alcohol levels, on average, as the middle-aged group.
• In the middle-aged group, 19 percent were Māori, however no Māori were in the older group. Dr Cheung says this could reflect cultural stigma around mental illness, barriers to culturally appropriate services, the higher status of kaumatua and kuia, lower life expectancies, and the lower proportion of older Māori living in the Counties Manukau DHB area.

“The older-aged people were a particularly vulnerable group,” says Dr Cheung. “In this age group, physical illnesses may cause or exacerbate depression. Other studies have shown that pain and loss of functioning commonly lead to feelings of hopelessness and distress in dealing with physical illnesses. These emotional struggles could increase suicide risk, particularly when independence and dignity is threatened and the person starts perceiving themselves as a burden.”

Depression is often under-reported and under-diagnosed in older people, who are more likely to report somatic (bodily) symptoms than emotional.

Internationally, there is little research into how to help older people who have self-harmed, but several studies suggest ‘talk therapy’ (interpersonal psychotherapy and problem-solving therapy) may reduce suicidal thoughts.

“Since depression is often associated with self-harm and suicide in older people, better screening for and treatment of depression is a very promising intervention,” says Dr Cheung.

He is involved in international research into using an assessment tool for identifying older people at high risk of suicide, which could lay the foundation for standard reporting and monitoring of elderly suicide.

“There has been a lack of focus on older people in the Ministry of Health’s suicide prevention strategy,” he says. ”This study underlines the fact that one size doesn’t fit all. Specific suicide prevention strategies are needed for older people who have different needs.”

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