Suicidal thoughts & self-harm

Thoughts about death and self-harm are not uncommon in older adulthood, especially in the later years of life. These thoughts are strongly associated with mental health conditions such as depression and anxiety, [1] and sometimes may result in self-harm or suicide. [2] For men and women, suicide rates are higher in older adulthood in comparison to younger age groups, and peak for men in older adulthood. [3] There may be multiple reasons why suicide rates are higher in older adulthood. What leads a person to consider suicide is complex and will often vary from person to person. [4] According to previous research, risk factors for suicide later in life include mental health disorders, physical illness, and functional or cognitive decline. [5, 6]

Self-harm (sometimes referred to as non-suicidal self-injury) is classified as someone taking steps to hurt themselves. Many people who self-harm are not attempting to end their life. However, self-harm can damage someone’s health, result in accidental death, and is a risk factor for future suicide attempts. [7] In older adulthood, self-harm is often a response to low feelings of control in one’s own life, feelings of social isolation, or an attempt to retain a sense of identity. [8] Self-harm is also higher among those living in residential aged care in comparison to those living in the community. [8]

This evidence theme on suicidal thoughts and self-harm is a summary of one of the key topics identified by a scoping review of mental health and wellbeing in aged care research. If you need more information on this topic, try using the PubMed search below.

Most reviews identified in our scoping review focused on suicidal thoughts and self-harm specifically in residential aged care. However, suicide risk in residential aged care is not well understood. While suicidal thoughts are an issue in aged care, there is little information on the prevalence of self-harm, suicidal thoughts, and suicidal behaviour in this population. [9] It is also not well understood how suicide risk is measured in long-term care, and how residential aged care facilities respond to these issues. [9]

According to multiple studies, suicidal thoughts are higher among residents in comparison to those living in the community, with between 5 and 33 per cent of residents reporting suicidal thoughts in the previous month. However, completed suicide is rare among those living in residential aged care. [6]

Risk factors for suicidal thoughts among those living in residential aged care include:

• Depression
• Social isolation 
• Loneliness
• Functional decline. [6]

In addition, risk factors for suicidal thoughts among residents living with dementia include:

• Recent diagnosis of dementia (<12 months)
• Living in a rural area
• Infrequent visit from relatives
• History of chronic disease
• Depressive symptoms
• Low social support
• Functional limitations in performing activities of daily living 
• Being on dementia medication. [10]

According to one study, the most vulnerable time for people in residential aged care when it comes to experiencing suicidal thoughts is during the first seven months after admission [6]. Most studies focused on risk factors relating to the individual, but some (potentially outdated) evidence suggests that some organisational characteristics (such as facility size, daily spending, and staff turnover) may also be relevant to suicide risk. [6] Organisational factors should be a focus of future research.

The effectiveness of certain interventions to reduce suicide risk have been investigated in previous studies. However, interventions to prevent suicidal thoughts or behaviours in residential aged care have not been rigorously evaluated. Therefore, no conclusions have been drawn regarding how effective they may be in preventing suicidal behaviours. [11] The most common approaches involve staff training. While the content of the training was not always clear in the studies, many involved similar approaches (e.g., increasing awareness of mental health conditions, potential warning signs and steps to take). No interventions demonstrated a significant impact on suicidal thoughts or behaviours of residents. However, one study demonstrated that certain staff training interventions improved the care of suicidal residents (e.g., more frequent measures taken, staff meetings, implementation of protocols). [11]

The reviews highlighted concerns about the methods used in some of the studies. For example: 

• Few studies have examined the issue of suicide among people receiving aged care, despite it being an important consideration for this group of people and their families. [6, 10] 
• Most studies only had a small number of participants. [6] 
• Studies were mostly conducted in residential settings, meaning little is known about suicidal thoughts and self-harm among people living in the community. [6] 
• There are issues with inconsistent terminology in this area (e.g., suicidal thoughts vs. suicide attempts), making it difficult to draw conclusions. [6] 

• Gain more knowledge about signs of suicidal thoughts. This page from Lifeline Australia may be a good place to start. 
• Undertake training about mental health and wellbeing in older adulthood. See resources below. 
• Refer or escalate concerns you may have about the psychological wellbeing of an individual or their carer.   

• Include routine mental health checks for people in your care. 
• Consider employing or contracting someone with psychological expertise within your organisation.  
• Provide regular staff training about recognising and responding to signs of suicidal thoughts.  
• Support and encourage staff to approach management with any concerns about individuals’ psychological wellbeing.

1. Bartels SJ, Coakley E, Oxman TE, Constantino G, Oslin D, Chen H, et al. Suicidal and death ideation in older primary care patients with depression, anxiety, and at-risk alcohol use. Am J Geriatr Psychiatry. 2002 Jul-Aug;10(4):417-27. 
2. Lawrence D, Almeida OP, Hulse GK, Jablensky AV, Holman CD. Suicide and attempted suicide among older adults in Western Australia. Psychol Med. 2000 Jul;30(4):813-21.
3. World Health Organisation. Preventing suicide: A global imperative [Internet]. Geneva: WHO; 2014 [cited 2023 Jun 27]. Available from: www.who.int/publications/i/item/9789241564779. 
4. BetterHealth Channel. Suicide [Internet]. 2018 [cited 2023 Jun 27]. Available from: www.betterhealth.vic.gov.au/health/conditionsandtreatments/Suicide.
5. Chang Q, Chan CH, Yip PS. A meta-analytic review on social relationships and suicidal ideation among older adults. Soc Sci Med. 2017;191:65-76.
6. Mezuk B, Rock A, Lohman MC, Choi M. Suicide risk in long-term care facilities: A systematic review. Int J Geriatr Psychiatry. 2014;29(12):1198-211.
7. healthdirect. Self-harm [Internet]. 2021 [cited 2023 Jun 27]. Available from: www.healthdirect.gov.au/self-harm.
8. Wand APF, Peisah C, Draper B, Brodaty H. Understanding self-harm in older people: A systematic review of qualitative studies. Aging Ment Health. 2018;22(3):289-98.
9. Gleeson H, Hafford-Letchfield T, Quaife M, Collins DA, Flynn A. Preventing and responding to depression, self-harm, and suicide in older people living in long term care settings: A systematic review. Aging Ment Health. 2019;23(11):1467-77.
10. Joshaghani N, Villa N, Badla O, Goit R, Saddik SE, Dawood SN, Rabih AM, Mohammed A, Raman A, Uprety M, Calero MJ. How residing in a long-term care facility affects suicidal risk in patients with dementia: A systematic review. Cureus. 2022;14(8).
11. Chauliac N, Leaune E, Gardette V, Poulet E, Duclos A. Suicide prevention interventions for older people in nursing homes and long-term care facilities: A systematic review. J Geriatr Psychiatry Neurol. 2020;33(6):307-15.