The study of self-harm in the elderly may provide a valuable insight into suicide. Episodes frequently involve a high degree of suicidal intent (Reference PiercePierce, 1987; Reference Merrill and OwensMerrill & Owens, 1990). As with completed suicide, there are high rates of depression in elderly people who self-harm (Reference PiercePierce, 1987; Reference Merrill and OwensMerrill & Owens, 1990), and unfortunately there are high rates of subsequent suicide, in particular in those with persistent depression (Reference Hepple and QuintonHepple & 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; Reference Beck and SteerBeck & Steer, 1993a ), the Beck Hopelessness Scale (BHS; Reference Beck and SteerBeck & Steer, 1993b ), the Suicide Intent Scale (SIS; Reference Beck, Schuyler, Herman, Beck, Resnik and LettieriBeck et al, 1974) and the 15-item Geriatric Depression Scale (GDS-15; Reference Sheikh, Yesavage and BrinkSheikh & 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 (Reference WengerWenger, 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; Reference Bifulco, Brown and EdwardsBifulco 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; Reference Folstein, Folstein and McHughFolstein 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.
Table 1 Elderly people with depression: comparison between those who did and did not have an episode of self-harm
| Self-harm group | Control group | P 1 | ||
|---|---|---|---|---|
| Age, years: median (IQR) | 77 (70-83.75) | 76 (70.75-81) | 0.85 | (z=70.2) |
| Female, % | 65 | 60 | 0.6 | (χ2=0.2) |
| Living alone, % | 71 | 59 | 0.2 | (χ2=1.5) |
| Poorly integrated social network, % | 76 | 52 | 0.02* | (χ2=5.6) |
| Any independent severe life event, % | 42 | 41 | 0.9 | (χ2=0.03) |
| Any major difficulty, % | 36 | 27 | 0.4 | (χ2=0.7) |
| Perceived community support: median (IQR) | 50 (10-90) | 80 (50-100) | 0.025* | (z=72.2) |
| Perceived support from family and friends: median (IQR) | 80 (41-100) | 90 (72-100) | 0.20 | (z=71.3) |
| Weekly contacts with statutory services, n: median (IQR) | 0 (0-2) | 1 (0-3.3) | 0.06 | (z=71.9) |
| Weekly contacts with family and friends, n: median (IQR) | 7 (3-8) | 4 (1-7) | 0.06 | (z=71.9) |
| Total weekly contacts, n: median (IQR) | 7.25 (5-10) | 6 (3.4-11) | 0.46 | (z=70.7) |
| GDS-15 score: median (IQR) | 9 (7-11.5) | 9 (6-10) | 0.32 | (z=71.0) |
| BDI score: median (IQR) | 23 (15-33) | 20 (14-26) | 0.1 | (z=71.6) |
| BHS 10-item score: median (IQR) | 7 (3-8.5) | 4 (2-7) | 0.047* | (z=72.0) |
| BHS 20-item score: median (IQR) | 12 (6.25-17) | 10 (6-13) | 0.21 | (z=71.3) |
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 χ2=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?’ (χ2=7.3, d.f.=1, P=0.007) and ‘no’ to the question ‘Do you think it is wonderful to be alive now?’ (χ2=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 (χ2=11.6, d.f.=3, P=0.009) and rate themselves as more sad (χ2=1.5, d.f.=3, P=0.04), but were less likely to cry (χ2=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 (Reference DurkheimDurkheim, 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 (Reference MurphyMurphy, 1982; Reference Lam, Brewin and WoodsLam et al, 1987; Reference Evans and KatonaEvans & 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.
Acknowledgements
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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