Suicide and self harm prevention strategy

Suicide and self harm prevention strategy

June 2024

The Older People’s Commissioner for Wales (OPCW) welcomes the opportunity to respond to the Welsh Government’s consultation on the draft suicide and self-harm prevention strategy.

Context

The mental health of many older people was negatively impacted by the pandemic as a result of a variety of factors including isolation, anxiety, distress and grief, as well as delayed and paused treatment.  Research undertaken with older people on behalf of the Commissioner in March 2021 showed that 17% had needed mental health support in the previous twelve months, but only 12% had sought it.  Extrapolated to the population as a whole, this could equate to almost 150,000 and 105,000 people respectively. Most people who die by suicide are not known to NHS mental health services.  The numbers of older people experiencing mental distress and not seeking help are a serious concern.

Many older people continue to be worried about the future.  Research undertaken on behalf of the Commissioner in March 2024 showed that levels of optimism among older people in Wales are declining sharply.  Only 39% of participants were optimistic about the future, while 37% were pessimistic.  This is a significant change from 80% and 8% respectively in 2021.  The same research showed that 17% of respondents expected to struggle with their mental health in the coming year.  It is essential that older people who need support with their mental health feel able to ask for support and can access it quickly, if progression to suicidal thoughts and intention is to be prevented.

Many of the problems older people experience are not directly related to their age but to social conditions and direct and indirect ageism which form barriers to accessing the connections, support and care needed.  For example, 19% of 65-69 year olds and 21% of 75-79 year olds are living in relative income poverty,[i] and 8% of older people in Wales report that they have been made to feel too old to receive health services.[ii]  Factors such as loneliness and social isolation, a loss of independence, or financial issues can all increase the risk of suicide amongst older people.[iii]

Older people are also often under-represented in many data sources, which causes difficulties when trying to identify the issues and barriers that may prevent us from ageing well.[iv]

Suicide and older people

Suicide rates

Suicide is a significant issue for older people, with some of the highest rates of suicide often found amongst those over the age of 65 years.[v] 21.7 per 100,000 men aged over 75 died by suspected suicide in Wales in 2022-23 and 16.5 per 100,000 men aged between 65 and 74.[vi]  For older women, the rates were 5.8 and 3.2 respectively.[vii]

Across England and Wales, there has been a steady slight increase in suicide rates in men aged 65-74 between 2016 and 2022.[viii]  Suicide rates in men and women over 75 had fallen or remained relatively constant since the peak in 2018.  However, there has been a slight increase in the number of people aged over 75 taking their own lives between 2021 and 2022.  The suicide rate for people aged over 90 also increased from 8 per 100,000 in 2021 to 13.3 per 100,000 in 2022.[ix] However, this is combined England and Wales data and numbers are likely to be small.

It is essential that Wales-specific age-banded data on suicide in older people is collected, tracked and monitored to generate a more accurate picture of suicide rates among older people in Wales and to develop any necessary targeted action.

High risk populations

It is positive that older people are recognised as a potentially high risk category in the draft Strategy.  However, the category of ‘people experiencing problems related to old age’ is poorly defined and needs further examination.   The problems experienced by older people encompass the way people are treated as a result of being older, as opposed to age itself, including inadequate care and support.  This category requires further consideration and explanation.

Older people are a diverse population group.  For example, older South Asian women are a higher risk group for suicide, compared with white people.[x]  The category of older people should be analysed to identify sub-categories of older people at higher risk of suicide than the general older population.   Data collected in relation to suicide and self-harm should be published by five-year age bands and where possible, enable cross referencing to other protected characteristics and developing targeted approaches for high-risk groups.

Methods

Methods of suicide also vary across age groups.  Older people are proportionately more likely to choose drowning as a method and are also more likely to use a sharp object than younger age groups.[xi]  While older people are less likely to use hanging or strangulation, this is still the most common method.  The category of ‘other’ methods is larger in people aged 65 and over and it is important to understand what this includes in order to take appropriate steps towards prevention.

All these issues need to be reflected as part of developing High Level Objective 2: ‘Co-ordinate cross-Government and cross-sectoral action which collectively tackles the drivers of suicide and reduces access to means to suicide’.

Self-Harm

There are clear links between self-harm and suicide,[xii] with research showing that a “past history of self-harm is a significant risk factor for suicide in older people”.[xiii] For this reason, it is critical that older people who self-harm have access to practitioners, with the skills to engage in specialist assessment and preventative intervention.[xiv]

Self-neglect as a form of self-harm and any link with suicide is a notable gap in the strategy.  Research shows that because of several predisposing factors (e.g. loneliness, isolation, and functional decline), self-neglect is a prevalent problem amongst older people.[xv] There is a strong correlation between depression in older people, and levels of self-neglect.[xvi] Some older people may self-neglect as a form of intentional self-harm.[xvii] The Welsh Government should include self-neglect within the strategy and commission research into any link with suicide as part of High-Level Objective 1:  Establish a robust evidence base for suicide and self-harm in Wales.

Many practitioners struggle when working with older people who self-neglect and must be supported to develop the skills and confidence to work effectively within these often highly challenging, complex situations.[xviii] The publication of Welsh Government practitioner guidance on working with those who self-neglect, a commitment made within the recently published Welsh Government National Action Plan to Prevent the Abuse of Older People in Wales, could help to address gaps in knowledge.[xix]  In the meantime, self-neglect should be included in High-Level Objective 4:  Increase skills, awareness, knowledge and understanding of suicide and self-harm amongst the public, professionals and agencies who may come into contact with people at risk of suicide and self-harm.

Abuse

Actions to reduce the risk of suicide among older people who experience abuse and/or neglect, must be included as part of the strategy for suicide prevention.  This is especially important given the identification of perpetrators and victims of sexual abuse as high-risk groups in Wales in the draft strategy.

Older people experience all of the same types of abuse as those in younger age groups [xx] including physical abuse, psychological or emotional abuse, sexual abuse and financial or material abuse.[xxi] It is recognised that domestic abuse is a “growing issue for older women”,[xxii] and that the likelihood of men being abused, increases with age.^[xxiii] Research commissioned by the OPCW highlights the significant challenges faced by older men when living within situations of domestic abuse,^[xxiv] both in terms of disclosing their experiences and in accessing care and support.

Research shows that because of their circumstances (e.g., increased isolation, reliance on others for physical care or illnesses like dementia), some older people are at increased risk of abuse.^[xxv] A study by the World Health Organisation indicated that worldwide, 1 in 6 people over the age of 60 is experiencing abuse. This means that 140,000 older people in Wales, could be at risk of, or experiencing abuse.[xxvi]

Abuse and/or neglect can have a devastating impact upon the lives of older people. The catastrophic impacts of abuse have resulted in some older people wanting to take their own lives; for these older people, suicide seems to be the only way to free themselves from their abusive situations.[xxvii] It is concerning that the correlation between older people’s experiences of abuse and their increased risk of suicide is not always recognised.[xxviii] A failure to recognise the potential for suicide in situations of abuse, can lead to vital opportunities for intervention and prevention being lost.

Homicide suicide arises where one partner murders the other, before taking their own life). Situations of homicide suicide are infrequent but when they do occur, most often arise amongst older couples.[xxix] Homicide-suicide may occur because of long-term abuse within a relationship or because the dynamics of relationships change: one partner becomes a carer for the other, for example, and struggles with the challenges of a caregiving role.

Plans for implementing the strategy should include details of how the issue of abuse and older people is being tackled in relation to suicide prevention, in particular regarding the identified high risk groups of perpetrators of abuse and victims of sexual abuse.

Communication

Research shows that many older people do not want to talk about issues related to “mental health” and “suicide” because they consider these subjects taboo.[xxx]  Older people may therefore look for different ways to express concerns related to their mental health, or to talk about thoughts of suicide. It is important that the strategy reflects older people’s language use and that practitioners are alert to the subtle cues that may be used by older people, when trying to talk about such issues.[xxxi]

Campaigns and promotional materials for support or services rarely focus on or include older people in the imagery and language used, which often leads to a perception that services are primarily for younger people.  Older people may not always identify with the kind of language used in promoting services, which could act as a further barrier to awareness of, and access to, the support available.

In addition, wider public narratives are often not inclusive of older people’s experiences and the media tends to focus on stories of self-neglect and self-harm among younger people.

The language used and best understood by older people as well as the most effective ways of reaching different audiences should inform High-level Objective 3: Deliver rapid and impactful prevention, intervention, and support to those groups in society who are the most vulnerable to suicide and self-harm through the settings with which they are most engaged; and High-level Objective 6:  Responsible communication, media reporting, and social media use.  This includes ensuring appropriate Welsh language terminology is used.

Action focussed on older people

The Commissioner notes the Welsh Government will develop a Delivery Plan outlining detailed activities and SMART objectives, and an evaluation framework which will set out how progress against the objectives in the strategy will be achieved.  The Delivery Plan, objectives and evaluation framework should set out action focussed on older people, particularly in relation to the issues described above, and include details of when and how older people will be engaged.  It is essential that older people are not treated as a homogenous group. Policy development needs to reflect the fact that we become more diverse as we age, i.e. in terms of experiences, interests, income, health and social relationships.  Older people may also form part of the other priority groups identified.

The issue of ageism – the stereotyping, prejudice and/or discrimination against people on the basis of their age or perceived age – should be explicitly addressed as part of the Delivery Plan, including how to overcome the specific issues older people may face as a result of potentially ageist attitudes from mental health professionals and services.

This is especially relevant as older people are less likely to be offered the full range of mental health support available than younger people.  The Royal College of Psychiatrists’ Suffering in Silence report highlighted the neglect of older people in mental health services in the UK.[xxxii] Particularly striking is the reference to a randomised control trial in which 121 doctors were given case studies of two identical patients with depression and asked to assess, diagnose and prescribe treatment for them. The only difference was their age: one was 39 and the other 81.  Diagnoses and treatments given to the younger patient were more appropriate than those for the older patient.  It is essential that ageism does not affect the mental health support available to older people, including suicide prevention and approaches to identifying people at risk of suicide.  Depression is recognised as a major contributor to suicide, making the findings of the Royal College of Psychiatrists report even more important.[xxxiii]

In addition, while technology and digital solutions have a significant role to play in mental health support, including the prevention of suicide and self-harm, there is also a need to focus on digital exclusion and on providing alternative channels and offline support for those people who cannot, or choose not to, access services digitally.  33% of people aged over 75 and 13% of people aged 65-74 do not use the internet, including Smart TV and handheld devices.[xxxiv]  Offline access to existing and future information, support and prevention services should be included from the outset as part of a user-centred design approach.

Conclusion

The Welsh Government’s suicide and self-harm prevention strategy should include or explore further the issues below:

• Reconsider, better define and explain the high-risk category of ‘people experiencing problems related to old age’ to reflect the fact that many problems experienced by older people encompass the way people are treated as a result of being older, as opposed to age itself, for example as a result of inadequate care and support.
• Ensure that High Level Objective 2 (‘Co-ordinate cross-Government and cross-sectoral action which collectively tackles the drivers of suicide and reduces access to means to suicide’) includes action to address the methods of suicide used by older people, as well as the rates and categories of older people at high risk.
• Publish data on suicide and self harm by five-year age bands and where possible, enable cross referencing to other protected characteristics, developing targeted approaches for especially high-risk groups.
• Include self-neglect within the strategy and commission research into any link with suicide as part of High-Level Objective 1; self-neglect should also be included in High-Level Objective 4 around increasing skills, awareness, knowledge and understanding.
• Explain how the issue of abuse and older people is being tackled in relation to suicide prevention, in particular regarding the identified high risk groups of perpetrators of abuse and victims of sexual abuse.
• Ensure that language and communications developed in connection to the strategy use wording and imagery that reflect and are meaningful to older people. This includes ensuring appropriate Welsh language terminology is used and promoted.
• The Delivery Plan, objectives and evaluation framework should set out specific action focussed on older people, including how the issue of ageism will be challenged.
• Explicitly include the issue of ageism as part of the Delivery Plan, explaining what measures will be taken to prevent ageism impacting the support offered to older people.
• Include offline access to existing and future information, support and suicide and self-harm prevention services from the outset as part of a user-centred design approach.

Notes

The Commissioner and her team would be happy to discuss any of these comments further.

[i] Stats Wales (2023) Pensioners in relative income poverty by age of the head of household. March 2023. Available at: https://statswales.gov.wales/Catalogue/Community-Safety-and-SocialInclusion/Poverty/pensioners/pensionersinrelativeincomepoverty-by-ageoftheheadofhousehold

[ii] ICM Unlimited. (2019) Older People in Wales Survey, data collected on behalf of the Older People’s Commissioner for Wales, 14-19 March 2019, 500 respondents aged 60+ living in Wales

[iii] National Council on Ageing. 2024. Suicide and Older Adults: What You Should Know. Available at: Understanding and Preventing Suicide in Older Adults (ncoa.org)

[iv] Older People’s Commissioner for Wales 2024, Understanding Wales’ Ageing Population: Key Statistics, March 2024 https://olderpeople.wales/resource/understanding-wales-ageing-population-key-statistics/

[v] Hafford-Letchfield, T. et al. 2022. Talking really does matter: Lay perspectives from older people on talking about suicide in later life. Frontiers in Psychology.

[vi] Public Health Wales 2024, Deaths by suspected suicide 2022-23, January 2024 https://phw.nhs.wales/services-and-teams/real-time-suspected-suicide-surveillance/deaths-by-suspected-suicide-2022-23/

[vii] Public Health Wales (2024) Deaths by suspected suicide 2022-23  Section 3 – Findings – Public Health Wales (nhs.wales).

[viii] Office for National Statistics 2023, Suicides in England and Wales: 2022 registrations. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2022registrations

[ix] Office for National Statistics 2023, Suicides in England and Wales: 2022 registrations. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/suicidesintheunitedkingdom/2022registrations Figure 3.

[x] Rethink Mental Illness, Black, Asian and Minority Ethnic (BAME) mental health, Black Asian and Minority Ethnic (BAME) mental health (rethink.org)

[xi] Office for National Statistics 2020, Recent trends in suicide: death occurrences in England and Wales between 2001 and 2018, https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/recenttrendsinsuicidedeathoccurrencesinenglandandwalesbetween2001and2018/2020-12-08#suicide-patterns-by-age

[xii] Dennis, M. et al. 2005. Self-harm in older people with depression: Comparison of social factors, life events and symptoms The British Journal of Psychiatry 186(6), pp. 538-539.

[xiii] Cheung, G. et al. 2017. Predictors for repeat self-harm and suicide among older people within 12 months of a self-harm presentation International Psychogeriatrics 29(8), pp. 1237-1245.

[xiv] Dennis, M. 2009. Suicide and Self-Harm in Older People. Quality in Ageing 10(1), pp. 16-23.

[xv] Papaioannou ES, Ismo, R. and Sirkka-Liisa, K. 2012. Self Neglect of the Elderly: An Overview. European Journal of Gerontological Practice 18(3), pp. 187-90.

[xvi] Braye, S., Orr, D., and Preston-Shoot, M. 2011. Conceptualising and Responding to Self-Neglect: The Challenges for Adult Safeguarding. Journal of Adult Protection 13(4), pp. 182-193.

[xvii] Hafford-Letchfield, T. et al. 2022. Talking really does matter: Lay perspectives from older people on talking about suicide in later life. Frontiers in Psychology.

[xviii] Braye, S., Orr, D., and Preston-Shoot, M. 2015. Learning lessons about Self-Neglect? An Analysis of Serious Case Reviews. Journal of Adult Protection 15(1)., pp. 3-11.

[xix] Welsh Government. 2024. Welsh Government National Action Plan to Prevent the Abuse of Older People in Wales. Available at: National action plan to prevent the abuse of older people [HTML] | GOV.WALES

[xx] Older Peoples Commissioner for Wales. 2021. Support Services for Older People Experiencing Abuse in Wales. Available at:  Support_Services_for_Older_People_Experiencing_Abuse_in_Wales.pdf (olderpeople.wales)

[xxi] NHS (2021). Abuse and Neglect of Vulnerable Adults. Available at Abuse and neglect of vulnerable adults (safeguarding) – NHS (www.nhs.uk)

[xxii] Milne, A. 2023. Older women and domestic abuse: through a glass darkly. The Journal of Adult Protection .

[xxiii] Office for National Statistics 2021. Domestic Abuse in England and Wales Overview (November 202):

Domestic abuse in England and Wales overview – Office for National Statistics (ons.gov.uk)

[xxiv] Older People’s Commissioner for Wales. 2022. Improving Support and Services for Older Men Experiencing Domestic Abuse. Available at: https://olderpeople.wales/wp-content/uploads/2022/08/Improving-support-and-services-for-older-men-experiencing-domestic-abuse.pdf

[xxv] Older People’s Commissioner for Wales (2021). Support Services for Older People Experiencing Abuse in Wales. Available at: https://www.olderpeoplewales.com/Libraries/Uploads/Support_Services_for_Older_People_Experiencing_Abuse_in_Wales.sflb.ashx

[xxvi] World Health Organisation (2017). Abuse of Older People on the Rise – 1 in 6 affected. Available at: https://www.who.int/news/item/14-06-2017-abuse-of-older-people-on-the-rise-1-in-6-affected

[xxvii] Lafferty, A. et al. 2012. Older People’s Experiences of Mistreatment and Abuse. Available at: Older people’s experiences of mistreatment and abuse. – Drugs and Alcohol

[xxviii] Salvatore, T. et al. 2018. Elder Abuse as a Risk Factor for Suicidal Behaviour in Older Adults. The Forensic Mental Health Practitioner 1(1), pp. 1-11.

[xxix] Salvatore, T. et al. 2018. Elder Abuse as a Risk Factor for Suicidal Behaviour in Older Adults. The Forensic Mental Health Practitioner 1(1), pp. 1-11.

[xxx] Hafford-Letchfield, T. et al. 2022. Talking really does matter: Lay perspectives from older people on talking about suicide in later life. Frontiers in Psychology.

[xxxi] Hafford-Letchfield, T. et al. 2022. Talking really does matter: Lay perspectives from older people on talking about suicide in later life. Frontiers in Psychology.

[xxxii] The younger patient was more likely to be diagnosed with depression and anxiety, but the older patient was diagnosed with dementia or a physical illness. Therapies prescribed for the younger patient were more likely to be relevant and included psychotherapy, pharmacotherapy, and referral for in-patient or specialist treatment. In contrast, the older patient was prescribed supportive counselling. Royal College Psychiatrists (2018) Suffering in silence: age inequality in older people’s mental health care. Available at:college-report-cr221.pdf (rcpsych.ac.uk).

[xxxiii] See ‘Depression’, refs 1-3, Mental Health Statistics, available at: Mental health statistics · MHFA England.

[xxxiv] OPCW, Understanding Wales’ Ageing Population:  Key Statistics, March 2024 https://olderpeople.wales/wp-content/uploads/2024/03/Understanding-Wales-ageing-population-March-24-.pdf