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

doi:10.3399/bjgp19X706049

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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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How this fits in

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.

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Table 1.

Characteristics of older adults

Patient ID	Sex	Ethnicity	Age, years	Health conditions^a	Psychosocial context^a	Start of self-harm	Support^a
F1	F	White British	62	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
F2	F	White British	72	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
F3	F	White British	60	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
M1	M	White British	67	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
F4	F	White British	65	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
F5	F	White British	62	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
M2	M	White British	61	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
F6	F	Ethnic minority British	62	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
M3	M	White American	60	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.

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Table 2.

Characteristics of support workers

Participant ID	Sex	Age, years	Role^a	Personal background
F7	F	46	Volunteer 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
F8	F	36	Support 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
F9	F	52	Support 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
F10	F	49	Main 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
F11	F	40	Support 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
M4	M	42	Support worker at older adults third-sector group	Previous counselling/psychology background Previous experience in research with older adults’ population and mental health
M5	M	50	Main 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.

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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

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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

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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