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Research

Role of primary care in supporting older adults who self-harm: a qualitative study in England

M Isabela Troya, Carolyn A Chew-Graham, Opeyemi Babatunde, Bernadette Bartlam, Faraz Mughal and Lisa Dikomitis
British Journal of General Practice 2019; 69 (688): e740-e751. DOI: https://doi.org/10.3399/bjgp19X706049
M Isabela Troya
School of Primary, Community and Social Care, Keele University, Keele, UK; researcher, School of Public Health, University College Cork, Republic of Ireland; researcher, National Suicide Research Foundation, Cork, Republic of Ireland.
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Carolyn A Chew-Graham
School of Primary, Community and Social Care, Keele University, Keele, UK; honorary professor of primary care mental health, Midlands Partnership Foundation Trust, St George’s Hospital, Stafford, UK.
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Opeyemi Babatunde
School of Primary, Community and Social Care, Keele University, Keele, UK;
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Bernadette Bartlam
School of Primary, Community and Social Care, Keele University, Keele, UK; senior research fellow, Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technical University Singapore, Singapore.
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Faraz Mughal
School of Primary, Community and Social Care, Keele University, Keele, UK.
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Lisa Dikomitis
School of Primary, Community and Social Care, Keele University, Keele, UK; research director, School of Medicine, Keele University, Keele, UK.
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    Figure 1.

    Flowchart of recruitment methods.

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    Figure 2.

    Summary of data analysis process.

    aThe research team discussed interpretation if adjustment of analysis was needed when data were inconsistent with initial analysis. PPIE = patient and public involvement and engagement.

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    Figure 3.

    Support avenues for older adults with self-harm behaviour.

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    Self-harm is the leading risk factor for suicide, with suicide being an increasing concern among older populations given the high suicide rates reported. Though research has shown that older adults who self-harm are in frequent contact with primary care owing to complex health conditions, to the authors’ knowledge, no research has explored the role of primary care in supporting this group. Using a qualitative approach, the presented study’s findings confirm that primary care is a potential avenue for effective self-harm management in older adults, and GPs are in a good position to manage and support older adults who self-harm. However, given the complex nature of self-harm, primary care may wish to work with other sectors (health, social, and third sectors) to comprehensively support older adults who self-harm, as recommended by the National Institute for Health and Care Excellence.
    • View popup
    Table 1.

    Characteristics of older adults

    Patient IDSexEthnicityAge, yearsHealth conditionsaPsychosocial contextaStart of self-harmSupporta
    F1FWhite British62
    • Personality disorder

    • Fibromyalgia, diabetes, heart disease, scoliosis, arthritis

    • Early start of mental health difficulties with child sexual abuse

    • Living alone, experiencing loneliness

    • Family history of mental illness

    • Experienced loss of children in adulthood

    • Limited mobility due to health

    Early teens
    • Long history of overdose hospital admissions

    • Limited family support

    • No longer attending group for self-harm

    • Medication seen by GP

    • Infrequent contact with CPN

    F2FWhite British72
    • Depression, alcohol misuse

    • Irritable bowel syndrome, arthritis, pancreatitis

    • Childhood sexual abuse and overall stressful upbringing

    • Interpersonal difficulties with family and family history of alcohol misuse

    • Early retirement due to mental health conditions

    Early childhood
    • Regularly attends sector group for self-harm

    • Previous contact with secondary care

    • Now overseen by GP

    F3FWhite British60
    • Personality disorder

    • High blood pressure, hypothyroidism

    • Multiple childhood stressors including sexual abuse, bullying, neglect, encounters with judiciary system

    • Family history of mental illness

    • Partner bereavement leading to experience of loneliness

    Early teens
    • Regularly attends sector group for self-harm

    • Medication overseen by GP

    • Support received by CPN

    • Long history of contact with primary and secondary care services

    M1MWhite British67
    • Depression

    • High blood pressure, heart disease

    • Early childhood experience of shame caused by secrecy of adoption

    • Experienced multiple losses of family members and friends

    • Health conditions disrupted life since early 40s leading to job loss

    40s
    • Multiple experiences with counsellors and contact with primary and secondary care

    • Regularly attends sector group for self-harm

    • Medication overseen by GP

    F4FWhite British65
    • Personality disorder, eating disorder, post-traumatic stress disorder

    • Osteoporosis, high blood pressure

    • Early childhood experiences of sexual abuse, violence, and neglect

    • Family history of mental illness

    40s
    • Recently joined third-sector self-harm group

    • Support from primary and secondary care services

    • Receives family support

    F5FWhite British62
    • Depression

    • Fibromyalgia, sciatica, ankylosing spondylosis, arthritis

    • Early childhood loss with death of mother, adopted by grandparents

    • Ongoing conflict with husband and interpersonal problems

    • Multiple bereavements

    • Health conditions affecting mobility and everyday life

    60s
    • Recently joined third-sector self-harm group

    • Previously received support from psychiatrist

    • Medication for depression overseen by GP

    • Receives family support

    M2MWhite British61
    • Pica, anxiety, post-traumatic stress disorder

    • Dystonia, heart failure, diabetes, liver disease, ulcerative colitis

    • Limited mobility due to health conditions

    • Several negative experiences with healthcare facilities

    • Loss of family members

    • First time talking about self-harm

    40s
    • Previously supported by counsellors

    • Currently sees psychiatrist

    • Attends third-sector dystonia group

    • No support for self-harm

    F6FEthnic minority British62
    • Depression, eating disorder

    • Arthritis, walking disability

    • Ongoing experience of violence and abuse

    • Escaped violent and life-threatening marriage, forcing themto re-locate

    • Self-identified as ethnic minority, highlighting difficulty to access support

    Early childhood
    • Received limited support for self-harm

    • Attends third-sector self-harm group

    • Soon to start seeing a private counsellor

    M3MWhite American60
    • Eating disorder, obsessive compulsive disorder, personality disorder

    • Anaemia

    • Divorce of parents experienced in childhood

    • Self-identified as homosexual, highlighting difficulty to access support

    • Highly educated and with previous experience in research

    • High levels of insight and self-awareness

    Early childhood
    • Talking therapy received for over a decade but stopped once moving to England

    • Attends service user group and is on the waiting list for a self-harm hospital programme

    • No family support

    • ↵a As reported by participants. CPN = community psychiatric nurse. F = female. ID = identifier. M = male.

    • View popup
    Table 2.

    Characteristics of support workers

    Participant IDSexAge, yearsRoleaPersonal background
    F7F46Volunteer lead at self-harm charity
    • Previous self-harm history

    • Started the only self-harm group in [city in North West England] because she saw the lack of support for people who self-harm

    • Has only recently started the group and supported people who self-harm

    • Looking for funding in order to make group a third-sector organisation for people who self-harm

    F8F36Support worker at self-harm third-sector group
    • No mention of self-harm or mental health history

    • Has worked with vulnerable populations, such as providing support for abused females in the past

    • Majority of experience supporting people who self-harm through observation of previous groups’ support worker

    F9F52Support worker at self-harm third-sector group
    • Previous self-harm history

    • Working as a support worker for many years but only recently with people who self-harm

    • Looking to receive further training for supporting people who self-harm

    F10F49Main facilitator at self-harm third-sector group
    • Traumatic experience in teens (rape) that led to self-harm

    • Received support from family and local third-sector group for self-harm in the last decade

    • Took over support worker/facilitator role in the group 11 years ago, while still in recovery for self-harm

    • Has completely stopped self-harming for 8 years

    • Multiple experiences with research projects as well as being a lay board member for various local suicide prevention boards

    F11F40Support worker at older adults’ third-sector group
    • No mention of self-harm or mental health history

    • Support offered to older adults focused on social services benefits and overall wellbeing

    • Has not received training on how to manage and deal with people who self-harm

    • Has trouble relating and understanding self-harm in members

    M4M42Support worker at older adults third-sector group
    • Previous counselling/psychology background

    • Previous experience in research with older adults’ population and mental health

    M5M50Main facilitator at self-harm third-sector group
    • Previous history of self-harm and suicidal attempts from early adolescence due to childhood sexual abuse

    • Only received support for their mental health when diagnosed with cancer in their adult years

    • Started facilitating group after volunteering at service user-led group

    • Participated in other research projects and actively involved in public speaking, and raising mental health and self-harm awareness

    • ↵a As identified by participants. ID = identifier. F = female. M = male.

    • View popup
    Box 1.

    Barriers to accessing primary care for self-harm in older adults

    External factors
    • Healthcare professionals’ attitudes and preconceptions

    • Structure of healthcare system

    • Disparity of care

    • Fragmented care delivery: mind–body dualism and priority to physical health care

    Practical barriers
    • Mobility restrictions

    • Transportation difficulties

    • Bureaucratic delays in healthcare delivery

    • Limited resources/staff

    Internal factors
    • Older adults’ attitudes and preconceptions of healthcare professionals

    • Reluctance to seek help

    • Health status of older adults

    • View popup
    Box 2.

    Facilitators to accessing primary care for self-harm in older adults

    External factors
    • Healthcare professionals’ attitudes and empathy

    • Staff with previous lived experience

    Structural factors
    • Accessible facilities

    • Provision of ongoing and regular support

    Internal factors
    • Previous positive treatment experiences influencing older adults’ attitudes towards staff

    • Health status of older adults

    • View popup
    Box 3.

    Recommendations to GPs working with older people who self-harm

    • Be aware that self-harm can occur in older adults, and though suicidal intent is not always present, it is important to consider patients’ suicidality

    • Consider the stigma attached to self-harm, and ensure an empathic approach so that the patient feels listened to

    • Be responsive to the distress associated with self-harm; do not focus exclusively on the physical sequelaeof self-harm

    • Consider offering longer appointments to provide comprehensive assessment and support to the patient for physical and mental health needs

    • Consider arranging a follow-up as part of ongoing assessment and management

    • Review current medication to assess whether these may act potentially as a method of self-harm, for example, overdose

    • Assess patient safety throughout the consultation and advise on access to means of potential self-harm

    • Liaise with the third sector and social care sector, or refer to specialist care where indicated

    • View the consultation as an opportunity to provide self-harm management and avoid repeat self-harm and suicide

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British Journal of General Practice: 69 (688)
British Journal of General Practice
Vol. 69, Issue 688
November 2019
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Role of primary care in supporting older adults who self-harm: a qualitative study in England
M Isabela Troya, Carolyn A Chew-Graham, Opeyemi Babatunde, Bernadette Bartlam, Faraz Mughal, Lisa Dikomitis
British Journal of General Practice 2019; 69 (688): e740-e751. DOI: 10.3399/bjgp19X706049

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Role of primary care in supporting older adults who self-harm: a qualitative study in England
M Isabela Troya, Carolyn A Chew-Graham, Opeyemi Babatunde, Bernadette Bartlam, Faraz Mughal, Lisa Dikomitis
British Journal of General Practice 2019; 69 (688): e740-e751. DOI: 10.3399/bjgp19X706049
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Keywords

  • deliberate self-harm
  • frail older adults
  • primary care
  • qualitative research

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