Deliberate self‐harm in older adults: A national analysis of US emergency department visits and follow‐up care

Abstract

Objective To examine mental health care received by older adults following emergency department (ED) visits for deliberate self‐harm. Methods This retrospective cohort analysis examined 2015 Medicare claims for adults ≥65 years of age with ED visits for deliberate self‐harm (N = 16 495). We estimated adjusted risk ratios (ARR) for discharge disposition, ED coding of mental disorder, and 30‐day follow‐up mental health outpatient care. Results Most patients (76.9%) were hospitalized with lower likelihoods observed for African American patients (ARR = 0.86, 99% CI = 0.79‐0.94) and patients with either one medical comorbidity (ARR = 0.91, 99% CI = 0.83‐0.99) or two to three comorbidities (ARR = 0.93, 99% CI = 0.88‐0.99). Hospitalization was associated with recent depression (ARR = 1.09, 99% CI = 1.03‐1.16) and recent psychiatric inpatient care (ARR = 1.13, 99% CI = 1.04‐1.22). Among patients discharged to the community (n = 3818), 56.4% received an ED mental disorder diagnosis. Predictors of an ED mental disorder diagnosis included younger age (65‐69 years; ARR = 1.53, 99% CI = 1.31‐1.78), recent mental health care in ED (ARR = 1.50, 99% CI = 1.29‐1.74) or outpatient (ARR = 1.62, 99% CI = 1.44‐1.82) settings, recent diagnosis of mental disorder (ARR = 1.61, 99% CI = 1.43‐1.80), and other/unknown lethality methods of self‐harm (ARR = 1.24, 99% CI = 1.01‐1.52). Among community discharged patients, 39.0% received 30‐day follow‐up outpatient mental health care, which was most strongly predicted by an ED diagnosis of mental disorder (ARR = 2.65, 99% CI = 2.25‐3.12) and prior outpatient mental health care (ARR = 2.62, 99% CI = 2.28‐3.00). Conclusion Most older adult Medicare beneficiaries who present to EDs with self‐harm are hospitalized. Of those who are discharged to the community, many are not diagnosed with mental disorder in the ED or receive timely follow‐up mental health care.

Predictive factors of nonfatal self-harm among community-dwelling older adults assessed for support services

“…Depression is a well-recognized risk factor for late-life suicidal behavior (Cheung et al, 2017a;Hawton and Harriss, 2006;Lapierre et al, 2011;Murphy et al, 2012;Salib et al, 2001;Schmutte et al, 2019;Troya et al, 2019a;Tsoh et al, 2005). In this study, the depression diagnosis (HR = 3.02) included people with a depression diagnosis for their current stay, receiving active treatment, or monitored but no active treatment.…”

“…Previous local studies have already established self-harm methods in older adults are mainly medication overdose (over 60%), laceration, and multiple means (Cheung et al, 2017a;Tan and Cheung, 2019). Although self-harm in older adults resembles suicide (Fässberg et al, 2019;Hawton and Harriss, 2008;Salib et al, 2001;Schmutte et al, 2019), recent qualitative studies suggested they occur along a spectrum of no-suicidal intent to high levels of intent (Troya et al, 2019b;Wand et al, 2018). It has been estimated that 73.5% of the subjects included in a late-life self-harm review reported suicidal intention (Troya et al, 2019a).…”

“…A previous New Zealand study found 2.1% of older adults who self-harm died by suicide within 12 months, a suicide rate that was over 200 times higher than the general older population (Cheung et al, 2017a). Self-harm in older adults is also associated with high suicide intent and closely related to suicide (Fässberg et al, 2019;Hawton and Harriss, 2008;Salib et al, 2001;Schmutte et al, 2019).…”

Longitudinal big data needs to meet the individual to inform self-harm and suicide prevention in older adults

“…In older adults, there are common risk factors for self-harm and suicide, and self-harm is more likely to be lethal with greater reported intent to die (Fassberg et al, 2019;Schmutte et al, 2019). However, not all people who self-harm do so with suicidal intent, and the two groups may be distinct (DeJong et al, 2010), with the outcome of death following self-harm sometimes related to external factors rather than intent or another meaning of the behavior (Linden and Barnow, 1997).…”

“…However, we already know much about these population-level risk factors (Troya et al, 2019). Research in this field needs to delve deeper, and explore the clinical trajectories and broader outcomes of older adults who self-harm in combination with qualitative data derived from the individuals themselves.In older adults, there are common risk factors for self-harm and suicide, and self-harm is more likely to be lethal with greater reported intent to die (Fassberg et al, 2019;Schmutte et al, 2019). However, not all people who self-harm do so with suicidal intent, and the two groups may be distinct (DeJong et al, 2010), with the outcome of death following self-harm sometimes related to external factors rather than intent or another meaning of the behavior (Linden and Barnow, 1997).…”