Medically Serious Suicide Attempts in a national cohort of older people attending Emergency Departments with a suicidal crisis

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Doherty, Geraldine McCarthy, Katerina Kavalidou, Vincent Russell, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9381367/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Internationally, there are higher rates of death by suicide among older adults, but self-harm is less common in this population. Medically Serious Suicide Attempts (MSSA) represent the most serious and potentially fatal self-harm presentations, but little is known about this in older people. Aims This study aimed to examine the characteristics associated with MSSA among older adults presenting to emergency departments (EDs). Method This study reports a cohort of people in Ireland presenting with suicide-related ideation and self-harm to EDs from 2018 to 2022. The data comes from database of the National Clinical Programme for Self-Harm and Suicide-related Ideation and includes 72,810 clinical presentations. The characteristics associated with MSSA were examined in those aged over 60. Results This study found that nearly twice as many episodes of self-harm in people aged over 60 years were graded “moderate” or "high” lethality, with one-fifth (20.3%, n=219) of attempts of those over 60 were rated as high lethality (11.6% under 60: p<0.001). People aged over 60 were more than twice as likely to require admission to a medical, surgical or critical care ward (n=943, 18.7%) compared with those under 60 (n=5711, 8.5%; p<0.001). The association between older age and high self-harm lethality remained significant after controlling for gender, ethnicity and substance use (Odds Ratio 1.23; CI: CI:1.157-1.305). Conclusion The higher proportion of MSSA amongst the older cohort, taken in the context of the higher suicide rates in this group, highlights the urgent need to understand better the variables associated with increased risk. Self-harm: Suicide Suicidal ideation Gerontology Emergency treatment. Figures Figure 1 Introduction Internationally, it is estimated that over 727,000 people die by suicide each year, with over 14 million episodes of self-harm annually. (WHO 2025 ; Moran et al. 2024 ) In the UK’s NICE guidelines, self-harm is defined as “intentional self-poisoning or injury, irrespective of the apparent purpose”. (NICE 2022 ) This includes acts which may or may not be associated with suicidal intent, and those with a degree of ambivalence. Self-harm as a key risk factor for suicide is a major public health concern. Self-harm is not necessarily associated with suicidal plans, and is associated with a range of functions and motivations. However, notwithstanding the range of motivations for the person involved, it is associated with death by suicide, and is an important risk factor for suicide. (Bostwick et al. 2016 ; Carroll, Metcalfe, and Gunnell 2014 ) Characteristics of severe self-harm While self-harm and suicidal ideation may occur in people without a diagnosed mental illness, they have been described in association with many mental illnesses. The most common diagnosis among those who die by suicide is depression, encompassing depressive episodes and recurrent depressive disorder. (Bruce et al. 2004 ) Self-harm has been found to be one of the most reliable factors associated with future death by suicide: about 40% of those who die by suicide have records of previous attempts. (Cavanagh et al. 2003 ) It has been calculated that self-harm is associated with a greatly increased risk of suicide in the year following an attempt by a factor of 66. (Hawton, Zahl, and Weatherall 2003 ) However, not all acts of self-harm convey the same risk. If we view suicidality as a spectrum that ranges from passive death wish all the way to suicide, with suicidal ideation and mild/ moderate/ severe self-harm in between, and with high severity self-harm adjacent to suicide, high severity self-harm may have more in common with suicide than other types of suicidal presentations. (Giner et al. 2014 ; Mohan et al. 2020 ) Medically serious suicide attempts (MSSA) or medically serious self-harm are defined as self-harm that would have been fatal without access to emergency care and that subsequently required hospitalisation for more than 24 hours in critical care, or surgery under general anaesthesia. (Levi-Belz and Beautrais 2016 ) While there have been a small number of studies which have examined the characteristics of MSSA, none have examined this in older people. Self-harm in older people In almost all countries, self-harm is more frequently seen in young people and adolescents, while older adults have the highest suicide rate. Among older US-based men, the incidence is 48.7/100,000 (which is more than four-fold the age-adjusted rate in the US of 11.1/100,000) and is higher again, with a rate of 140 per 100,000 among older males in rural regions of China (Conwell and Thompson 2008 ). Likewise, the definition of "older people" can vary somewhat between countries. Studies from the US defines older people” as those aged 65 years and some Chinese studies set the cut-off at 60 years (Conwell and Thompson 2008 ). Rates of death by suicide increase with age past the age of 60; there is evidence that age has the opposite impact on rates of self-harm, with a lowering incidence over time. Hawton and Harriss examined the lifetime incidence of suicide related to self-harm, and reported a high ratio of self-harm to suicide (200:1) in those aged under 20 years, but this ratio was much lower in older adults (10:1 in those over 60 years) (Hawton and Harriss 2008 ). This phenomenon even applies to older people who died by suicide. In the context of both the elevated rate of suicide as a cause of death among older adults, and self-harm’s role as a key risk factor for suicide, identifying the characteristics of self-harm in this population is a clinical priority. Additionally, understanding the demographic and clinical factors associated with suicidal behaviours, along with patterns of engagement with services, is crucial for tailoring interventions and clinical services to meet their needs compassionately and effectively. Exmainig the variables associated with high-lethality self-harm can help us better identify those at highest risk, including individuals who present with MSSA. Objectives This study aimed to identify the clinical and sociodemographic characteristics of older adults who present with higher severity self-harm, that meets the criteria for MSSA. Methods Design & setting This cohort study is based on a national dataset collected and maintained by the Irish Health Service Executive’s National Clinical Programme for Self-Harm and Suicide-related ideation (NCPSHI). Since 2010, the NCPSHI has ensured that all patients who present to the ED with suicidal ideation or self-harm receive a full biopsychosocial assessment promptly (HSE 2022 ). The NCPSHI has set the standards for both the biopsychosocial assessment and the following clinical management of people presenting to EDs with suicidal ideation or self-harm. The Clinical Nurse Specialists (CNSs) of the NCPSHI play a key role in coordinating data collection to monitor and evaluate programme outcomes, in addition to their clinical duties in performing clinical assessments. These data are anonymised upon entry into the NCPSHI electronic template, and this dataset includes all individuals seen in the ED, whether by CNSs and other members of the consultation-liaison psychiatry teams during working hours, or by on-call psychiatry clinicians outside core working hours (Hoare et al. 2024 ) Participants This study is based on the years 2018–2022, using a national dataset which comprises a complete five-year cohort of 72,810 presentations (HSE 2022 ). This data comprises anonymised information from Irish EDs serving adult patients. Data are de-identified at the point of submission and reflect the number of presentations and not the individuals presenting. Variables & measurement Sociodemographic information is collected as part of the biopsychosocial assessments. Since 2018, age groups have been recorded under the following brackets: 60. Other sociodemographic information collected includes ethnic background (as defined and categorised by Ireland’s Central Statistics Office), gender, employment status (collected since January 2020), and hospital. The dataset also includes clinical information regarding whether the individual presented with self-harm or ideation, lethality of self-harm act (since the beginning of 2020), details of suicidal thoughts (i.e. regarding suicide or self-harm), any substance use which may have contributed to the presentation, if medical treatment was required (whether the person required medical/surgical/ critical care admission for physical treatment of self-harm), and prior or current engagement with a mental health service (including if the individual is attending a statutory, voluntary or private service). In addition, the database holds information on the source of referral to the ED and on onward referral following assessment (including psychiatric admission and referral to a range of statutory services and voluntary agencies). The NCPSHI requires that the following suicide prevention interventions are completed and recorded for each presentation. These include, in addition, the completion og a biopsychosocial assessment, an emergency safety plan, the collection of a collateral history and, where possible, next-of-kin engagement in the development of a discharge plan. A summary letter is sent to the individual’s GP within one working day, and if appropriate, copied to the individual’s mental health service. The database records bridging or follow-up calls (within 72 hours of assessment), another key evidence-based suicide prevention intervention. Medical lethality : In this dataset, two measures were used to assess lethality: the lethality measure from the dataset (limited to years 2020–2022, a measure input by the clinical nurse specialist collecting the data at the site), and the need for medical admission as a proxy for medical seriousness or lethality: this latter group represents MMSA proper. Power calculation As this study was a full retrospective cohort study of a nationally provided service over five years, and included all presentations (n = 72,810); a power calculation was not required. Older people represented a smaller subgroup (n = 5,041). Statistical Analysis The data were input into SPSS and analysed to assess the characteristics of suicidality in the population aged over 60 years, using descriptive statistics, specifically chi-square tests. This study developed a multivariable model in order to explore the relationship between older age and MSSA, and controlled for confounding factors. We examined the relationship between MSSA and psychiatric admission using logistic regression and controlled for gender, year of presentation, co-occurring substance use, and medical admission. The significance level was set at 0.05. Results This NCPSHI database comprised presentations of all people presenting with suicidal ideation and self-harm to EDs across Ireland for the years 2018 to 2022. The majority of those presentations were from people under 60 years of age (n=67,603), with 5,041 presentations from those aged over 60 (see Table 1). The number of presentations to EDs increased significantly from 2018 to 2022 in both age groups (over and under 60 years). However, the presentations of those aged over 60 years increased to a significantly higher degree (n = 1316, 26.1%) compared with those aged under 60 (n = 15351, 22.7%, p < 0.001). Overall, the number of older people attending EDs nationally with self-harm increased from 409 presentations in 2018 to 439 in 2020 (107% of the 2018 attendance). In the aftermath of the COVID-19 pandemic, the numbers continued to increase, with 528 presentations in 2022, 129% of the 2018 presentations. The increase was more marked in men (an increase of 138%) than in women (an increase of 123%), as illustrated in Figure 1. There were significant differences in self-harm proportions across age brackets. The highest proportions of self-harm were in the 20-29 age bracket (n=10,593, 29.7%, p<0.001), while the lowest proportions were in the group aged over 60 years (n=2,193, 6.1%, p<0.001). White Irish was overwhelmingly the most common ethnicity among presentations in both the under-60s and over-60s, representing a greater proportion of the over-60s: 85.2% vs 91.9%, p < 0.001. In all age groups, the most common method of self-harm was drug overdose, and this formed a significantly greater proportion of the over-60 age group: (n=1,471) 30.2% compared with (n=17,619) 27.3% in the under-60s, p<0.001 (Table 1). Presentations from those aged under 60 had a higher prevalence of drug use, compared to those over 60, who had a higher prevalence of alcohol use only. A higher proportion of those over 60 years were currently attending a mental health service; n = 1828, 38.1%. Table 1: Clinical characteristics of people aged >60years compared with those aged under 60 years N (%) Total (n=72,644) 60 (n=5,041) P value (c 2 ) Self-Harm Yes No (suicide-related ideation) 35695 (51.5) 33625 (48.5) 33502 (52) 30952 (48) 2193 (45.1) 2673 (54.9) <0.001 (86.5) Type of Self Harm Cutting Attempted Drowning Drug and Alcohol overdose Drug Overdose Attempted Hanging Jumping from a height Shooting Multiple methods Attempted suffocation Other 8243 (11.9) 811 (1.2) 2052 (3) 19090 (27.5) 2126 (3.1) 329 (0.5) 21 (0) 1172 (1.7) 18 (0) 1833 (2.6) 8006 (12.4) 739 (1.1) 1952 (3) 17619 (27.3) 2060 (3.2) 309 (0.5) 18 (0) 1117 (1.7) 17 (0) 1665 (2.6) 237 (4.9) 72 (1.5) 100 (2.1) 1471 (30.2) 66 (1.4) 20 (0.4) <10 55 (1.1) <10 168 (3.5) <0.001 (479.1) Substance Use Alcohol and Drugs Alcohol only Drugs only No drugs or alcohol 9318 (12.8) 16114 (22.2) 6352 (8.7) 40860 (56.2) 9227 (13.6) 14781 (21.9) 6275 (9.3) 37320 (55.2) 91 (1.8) 1333 (26.4) 77 (1.5) 3540 (70.2) <0.001 (1068.1) Attending mental health team No/Unknown Yes 42713 (63.4) 24697 (36.6) 39743 (63.5) 22869 (36.5) 2970 (61.9) 1828 (38.1) 0.029 (4.8) Referred to ED by Mental health team General practitioner Police Other 649 (0.9) 8695 (12) 3959 (5.5) 59022 (81.6) 576 (0.9) 7984 (11.9) 3790 (5.6) 54950 (81.6) 73 (1.5) 711 (14.1) 169 (3.4) 4072 (81) <0.001 (259.0) Assessment Location ED Medical/Surgical/ICU Not assessed 58379 (80.4) 6654 (9.2) 7589 (10.5) 54633 (80.8) 5711 (8.5) 7239 (10.7) 3746 (74.3) 943 (18.7) 350 (6.9) <0.001 (627.4) Reasons not assessed Left ED before assessment completed RIP Transferred to another site Not recorded 5780 (76.2) 65 (0.9) 1592 (21) 153 (2) 5537 (76.5) 55 (0.8) 1503 (20.8) 144 (2) 243 (69.2) 10 (2.8) 89 (25.4) <10 <0.001 (24.0) Subsequent admission to psychiatry No Yes 54103 (83.2) 10951 (16.8) 50565 (83.8) 9799 (16.2) 3538 (75.4) 1152 (24.6) <0.001 (215.7) Next referrals Specialist MHS Other 27245 (50.9) 26331 (49.1) 25387 (50.7) 24678 (49.3) 1858 (52.9) 1653 (47.1) 0.11 (7036.7) Time to admission/discharge <6 hours 9 hours 42416 (67.8) 10321 (16.5) 9819 (15.7) 39650 (68.2) 9612 (16.5) 8847 (15.2) 2766 (62.2) 709 (15.9) 972 (21.9) <0.001 (138.9) Consistent with the methodology of the National Clinical Programme for Self-Harm and Suicide-Related ideation and filed with less than 10 presentations is presented as <10. When the relationship between age and lethality was examined, two measures were used to assess lethality: the lethality measure from the dataset (limited to years 2020-2022) and the need for medical admission as a proxy for medical seriousness or lethality: this group representing MMSA proper. Lethality of attempt in the over 60s was significantly more likely to be rated as moderate or high compared with those under 60 years. Over one-fifth (20.7%, n=216) of self-harm in those over 60 was rated as being of high lethality, nearly double the proportion (11.8%; n=1761) in those under 60, p<0.001. People aged over 60 years were significantly more likely to be assessed on a medical or surgical ward or in the ICU (n=943, 18.7%) compared with the under-60-year cohort (n=5711, 8.5%; p<0.001). When we examined the relationship between the objective measure of lethality (need for admission for medical/ surgical treatment) with the subjective measure which was input into the database by the clinicians at the sites (only available for a portion of the sample), there were significant differences between the two groups on bivariate analysis, both in the group as a whole and in those aged over 65 years (table 2). Table 2: Measures of lethality in the whole population and in those aged over 60 years Total Medically treated in ED Admitted to a medical /surgical/ critical care ward P value (c 2 ) Lethality measure input by coder All N= 16,009 N= 13,209 N= 2800 Low Medium High 7,956 (49.7) 6,076 (38) 1,977 (12.3) 7356 (92.5) 4597 (75.7) 1256 (63.5) 600 (21.4) 1479 (52.8) 721 (25.8) <0.001 (1236.8) Over 60s N= 1,043 N= 711 N= 332 Low Medium High 402 (38.6) 425 (40.7) 216 (20.7) 323 (45.5) 269 (37.8) 119 (16.7) 79 (23.8) 156 (47) 97 (29.2) <0.001 (49.2) This table compares measures of lethality in the whole population and in those aged over 60 years for whom both measures of lethality are available, the measure inputted by the coder (2020-2022) and the proxy measure: need for medical treatment as an inpatient (n=16,009) The patients aged 60 years and over were more likely to be admitted to a mental health inpatient unit (n=1152, 24.6%) compared with those aged under 60 (n=9799, 16.2%), p<0.001. The ratio of low to high lethality self-harm was 4.4:1 in the under-60s and 1.9:1 in the over-60s, using the measure in the database, and the ratio of ED-treated to medically admitted was 9.6:1 in the under-60s and 3.9:1 in the over-60s. On logistic regression, the association between older age and MSSA (using the proxy measure of admission to a medical/ surgical/ critical care bed) was statistically significant with an Odds Ratio (OR) of 1.32; CI:1.244-1.399). This remained significant after controlling for gender, ethnicity, attending mental health services and substance use. (OR 1.23; CI:1.157-1.305; p<0.001: see table 3). Female gender was similarly significantly associated with MSSA (OR 1.82; CI:1.763-1.878; p<0.001), as was active substance use (OR 0.7; CI:0.679-0.723; p<0.001). Table 3: Logistic regression examining the relationship between higher lethality self-harm and age Odds Ratio p-value Confidence interval Model 1 Age (under v over 60 years) 1.32 <0.001 1.244-1.399 Model 2 Age (under v over 60 years) 1.23 <0.001 1.157-1.305 Gender 1.82 <0.001 1.763-1.878 Ethnicity 1.08 0.005 1.022-1.129 Substance use 0.70 <0.001 0.679-0.723 Attending mental health services 0.83 0.206 0.948-1.012 Model 3 (over 65 years only) Gender 2.01 <0.001 1.791-2.264 Ethnicity 1.27 0.044 1.006-1.612 Substance use 0.79 <0.001 0.699-0.901 Attending mental health services 0.88 0.208 0.958-1.219 Models 1 and 2 show the relationship between higher lethality self-harm (dependent variable) and age; and Model 3 shows the variables associated with high lethality self-harm in those aged over 60 years When we ran this model in those aged over 60 years only (removing age as a variable, but retaining gender, ethnicity, attending mental health services and substance use), female gender was significantly associated with MSSA (OR 2.01; CI:1.791-2.264; p<0.001). Discussion Our results illustrate the significant differences in the older individuals who present to Irish EDs with MSSA or high lethality self-harm compared with younger people, where previously a paucity of data existed. This study reported a year-on-year increase in the number of older people attending the ED with self-harm between 2018 and 2022. It also found that people aged over 60 years attending EDs with self-harm and suicidal ideation represented a small population compared with younger people (6.1% of the total). However, self-harm episodes were significantly more likely to be graded “moderate” or "high” lethality. One-fifth of the self-harm in those over 60 years was rated as ‘high lethality’. People aged over 60 years were more than twice as likely to require admission to a medical, surgical or critical care ward compared with those aged under 60. This may be seen as a proxy measure for medical lethality. Older age was strongly associated with medical admission on logistic regression after controlling for other variables such as gender, age, ethnicity, substance use and previous attendance at mental health services. Older people were significantly more likely to have pre-existing contact with mental health services or to have been referred to the ED by a health professional. In addition, older people were significantly more likely to require admission to a psychiatric ward, which indicates a higher degree of psychiatric illness in this population. This may also reflect barriers to access to services, for example, while all persons aged over 70 years have free primary healthcare, this is not the case for those aged under 70, where it is means-tested, which means that about 2/3 of people there have a cost associated with attending their primary healthcare provider. These findings are consistent with the literature, which shows that older people are overrepresented among those admitted with more medically serious self-harm. This is an important population to identify, as there is evidence that people who experience medically serious self-harm have much in common with those who die by suicide. (Beautrais 2001) These findings are reflected in the proportion of presentations that require admission for medical or surgical treatment of their injuries, as well as in the nurse-rated lethality score. It is worth noting that critical care admission for any cause is associated with an elevated suicide risk. Fernando et al, in their study of 423,060 people who had required critical care admission, reported an increased rate of both suicide and self-harm, with hazard ratios of 1.15 and 1.22, respectively. (Fernando et al. 2021) While this study reported a lower mean age in those who had an episode of self-harm or suicide following a critical care admission, these outcomes were associated with higher rates of premorbid mental ill-health. However, this study did not specify whether any of the included patients had a critical care admission precipitated by an act of self-harm. (Fernando et al. 2021) Given that psychiatric admission within the past 3 months is associated with suicide rates up to 100 times the population rates, the subgroup of patients requiring critical care admission due to self-harm is likely to have significantly elevated suicide risk. (Meehan et al. 2006; Chung et al. 2017) The ratio of low to high lethality of self-harm of 1.9:1 compared with in those aged under 60, where it is 4.4:1, suggests that, in general, episodes of self-harm in older people are more frequently associated with a higher level of medical lethality. While this study does not allow a direct comparison with suicide rates, the differing ratios in self-harm between those aged above and below 60 years suggest there is a difference in the function of self-harm in this population. These may be different points on a spectrum ranging from suicidal ideation through to death by suicide as conceptualised by Mohan et al. (Mohan et al. 2020). This reflects a similar pattern to that described by Hawton and Harriss, who reported a much higher ratio of self-harm to suicide, of 10:1 in individuals aged 60 years. (Hawton and Harriss 2008) Although the database does not capture psychiatric diagnoses, the significantly higher proportions of older people requiring psychiatric admission may be seen to represent a greater burden of mental illness in this population. Di Lorenzo et al likewise reported that a greater proportion of retired persons required psychiatric hospitalisation for self-harm compared with other reasons for admission (4.7% v 3.9%). (Di Lorenzo et al. 2024) An Italian study of older people who accessed psychiatry admission for self-harm reported that the majority (62.3%) had never had a previous admission, and 46.4% were not attending mental health services at the time of the self-harm, which precipitated the admission: higher than the 38.1% attending in this study. (Gramaglia et al. 2021) There is conflicting evidence from the literature regarding the impact of the COVID-19 pandemic on older people and medically serious self-harm, with the systematic review by Pathiranthna and colleagues reporting elevated rates in older people associated with pre-existing mental illness and financial difficulties identified as contributing factors. (Pathirathna et al. 2022) On the other hand, studies by Corbe and colleagues and by Beneria and colleagues reported that younger people were disproportionately affected by self-harm in France and Spain, respectively (Beneria et al. 2024; Corbé et al. 2023). Our study showed a steady increase in older people’s attendance at EDs with self-harm and suicidal ideation pre-pandemic over the years 2018 - 2020. The numbers continued to increase further in the aftermath of the pandemic. This suggests unmet need in the community, and perhaps an increased willingness to seek help, unexpected in the context of the focus on “cocooning” older adults during this pandemic. Overall, these findings are consistent with the literature, suggesting that, in the midst of the pandemic, there was no major increase in presentations; however, this increase was more likely to occur after the initial crisis of the pandemic. (Steeg et al. 2022; McIntyre et al. 2021). One single-site study from Japan, which examined the medical lethality of patients presenting to an urban hospital, reported significantly elevated lethality among older men (Tsuchida et al. 2023). Our findings are consistent with those reported by Szucs et al, which found that medically serious self-harm was associated with older age. (Szücs et al. 2025) The high rates of critical care admissions for older adults are similarly surprising given the pressure on critical care beds in the pandemic. Cai et al reported in their systematic review that there was a significantly elevated suicide rate among older people (Cai et al. 2022). One systematic review, which examined high medical lethality self-harm in older people, did not find any significant association between severity of lethality and age or gender. (Barker, Oakes-Rogers, and Leddy 2022). The prevalence of higher lethality self-harm attempts in older people attending Irish EDs suggests an urgent need to identify and understand the characteristics of self-harm in this population. This information is key to developing treatments and responsive (even proactive) services that meet the specific needs of this high-risk group. The impact of gender on medically serious self-harm suggests that women are more likely to require a medical admission for self-harm, which indicates that older women present with MSSA at twice the rate of men, despite having lower rates of suicide. This is consistent with existing evidence, which suggests that women have higher rates of more serious episodes of self-harm as they age. (Clements et al. 2025; Troya et al. 2019) Strength and Limitations The strengths of this paper include the utilisation of a national data source of a cohort presenting to EDs with suicidal ideation and /or self-harm to examine the characteristics of older adults. The comparison between older and younger people who present with self-harm identified key differences in sociodemographic and clinical characteristics between the two groups. The retrospective nature of the register is a limitation of the study. However, the population studied is a complete clinical sample. It is further limited in the presentation-based rather than individual-based nature of the dataset; therefore, repeated presentations of individuals are not captured. The lethality measure used for multivariable analysis, utilised the need for medical/surgical/ critical care admission as a proxy for a more direct method of assessing lethality. While this is an Irish national database, the findings are likely generalisable to other international settings where emergency care and all mental healthcare is free at the point of access. Conclusions Our results indicate significant differences in older people compared with younger people who attend the ED with suicidal ideation or high lethality self-harm. The higher prevalence of MSSA amongst the older cohort makes it a clinical priority to understand the variables associated with increased risk. The higher psychiatric admission rates identified in this cohort are important in resource allocation and service development. There is a need for further work to better understand the characteristics, motivations and clinical needs of older adults who attend the ED with suicidal ideation or self-harm, especially MSSA. Specifically, further information regarding the medical lethality and the perceived lethality, along with details of the types of difficulties, especially mental illness, which precipitated the event, would greatly enhance our understanding of this population. Declarations Acknowledgements: The authors thank the National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland for allowing access to their data. Author Contribution Statement: A.M.D. served as lead for conceptualisation, formal analysis, visualisation and writing. F. H. served in a supporting role for conceptualisation, formal analysis and writing. K.K., V.R., G.McC., and M.N. contributed equally to investigation and data curation and contributed equally to writing (review and editing). Ethics Considerations: The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. All procedures involving human subjects/patients were approved by the Clinical Research Ethics Committee of University College Dublin LS-LR-22-167. Consent to participate: Not applicable. The authors assert that the anonymised registry was obtained from the National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland. As the data represent presentations, and not individuals, and were fully anonymised and collected as part of routine care, individual-level consent was not required, and the requirement for informed consent was waived by the Ethics Committee (Clinical Research Ethics Committee of University College Dublin LS-LR-22-167). Consent for publication: Not applicable Declaration of conflicting interest: None. Funding Statement: This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Data Availability Statement : The data that support the findings of this study are available from the National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland. Restrictions apply to the availability of these data, which were used under licence for this study. Data are available with the permission of the National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland. References Barker J, Oakes-Rogers S, Leddy A. What distinguishes high and low-lethality suicide attempts in older adults? A systematic review and meta-analysis. J Psychiatr Res. 2022;154:91–101. Beautrais AL. Suicides and serious suicide attempts: two populations or one? Psychol Med. 2001;31:837–45. 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Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS ONE. 2014;9:e89944. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med. 2003;33:395–405. Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2017;74:694–702. Clements C, Bickley H, Hawton K, Geulayov G, Waters K, Ness J, Kelly S, Townsend E, Appleby L, Kapur N. 2025. 'Self-harm in women in midlife: rates, precipitating problems and outcomes following hospital presentations in the multicentre study of self-harm in England'. Br J Psychiatry: 1–7. Conwell Y, Thompson C. Suicidal behavior in elders. Psychiatr Clin North Am. 2008;31:333–56. Corbé J, Montout C, Fares A, Belhadj I, Boudemaghe T, Mura T, Lopez-Castroman J. A comprehensive study of medically serious suicide attempts in France: incidence and associated factors. Epidemiol Psychiatr Sci. 2023;32:e2. Di Lorenzo R, Scala C, Reami M, Rovesti S, Ferri P. Suicide risk among adult subjects hospitalized in an acute psychiatric ward: 6-year retrospective investigation. BMC Public Health. 2024;24:3113. Fernando SM, Qureshi D, Sood MM, Pugliese M, Talarico R, Myran DT, Herridge MS, Needham DM, Rochwerg B, Cook DJ, Wunsch H, Fowler RA, Scales DC, Bienvenu OJ, Rowan KM, Kisilewicz M, Thompson LH, Tanuseputro P. and K. Kyeremanteng. 2021. 'Suicide and self-harm in adult survivors of critical illness: population based cohort study', Bmj , 373: n973. Giner L, Jaussent I, Olié E, Béziat S, Guillaume S, Baca-Garcia E, Lopez-Castroman J, Courtet P. Violent and serious suicide attempters: one step closer to suicide? J Clin Psychiatry. 2014;75:e191–7. Gramaglia C, Martelli M, Scotti L, Bestagini L, Gambaro E, Romero M, Zeppegno P. Attempted Suicide in the Older Adults: A Case Series From the Psychiatry Ward of the University Hospital Maggiore Della Carità, Novara, Italy. Front Public Health. 2021;9:732284. Hawton K, Harriss L. How often does deliberate self-harm occur relative to each suicide? A study of variations by gender and age. Suicide Life Threat Behav. 2008;38:650–60. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry. 2003;182:537–42. Hoare F, O'Donoghue A, Sweeney C, McCarthy G, Kavalidou K, Russell V, Norton MJ, Doherty AM. Assessing the characteristics of suicidal ideation and self-harm in a national older adult population attending emergency departments across Ireland: cohort study protocol. BMJ Open. 2024;14:e087797. HSE. 2022. National Clinical Programme for Self-Harm and Suicide-related Ideation. In, edited by National Clinical Programme for Self Harm and Suicide Related Ideation – Implementation Advisory Group. Dublin: HSE, CPsychI, ICGP. Levi-Belz Y, Beautrais A. 'Serious Suicide Attempts' Crisis. 2016;37:299–309. McIntyre A, Tong K, McMahon E, Doherty AM. COVID-19 and its effect on emergency presentations to a tertiary hospital with self-harm in Ireland. Ir J Psychol Med. 2021;38:116–22. Meehan J, Kapur N, Hunt IM, Turnbull P, Robinson J, Bickley H, Parsons R, Flynn S, Burns J, Amos T, Shaw J, Appleby L. Suicide in mental health in-patients and within 3 months of discharge. National clinical survey. Br J Psychiatry. 2006;188:129–34. Mohan C, Tembo V, McNicholas B, Doherty AM. 2020. 'Defining high risk by clinical lethality: The different characteristics and management of the survivors of serious self-injury admitted to critical care, compared with lower lethality self-injury'. Gen Hosp Psychiatry. Moran P, Chandler A, Dudgeon P, Kirtley OJ, Knipe D, Pirkis J, Sinyor M, Allister R, Ansloos J, Ball MA, Chan LF, Darwin L, Derry KL, Hawton K, Heney V, Hetrick S, Li A, Machado DB, McAllister E, McDaid D, Mehra I, Niederkrotenthaler T, Nock MK, O'Keefe VM, Oquendo MA, Osafo J, Patel V, Pathare S, Peltier S, Roberts T, Robinson J, Shand F, Stirling F, Stoor JPA, Swingler N, Turecki G, Venkatesh S, Waitoki W, Wright M, Yip PSF, Spoelma MJ, Kapur N, Christensen. Lancet. 2024;404:1445–92. 'The Lancet Commission on self-harm'. NICE. Self-harm: assessment, management and preventing recurrence. Guideline number NG225. In. London: National Institute for Health and Care Excellence; 2022. Pathirathna ML, Nandasena H, Atapattu A, Weerasekara I. Impact of the COVID-19 pandemic on suicidal attempts and death rates: a systematic review. BMC Psychiatry. 2022;22:506. Steeg S, John A, Gunnell DJ, Kapur N, Dekel D, Schmidt L, Knipe D, Arensman E, Hawton K, Higgins JPT, Eyles E, Macleod-Hall C, McGuiness LA, Webb RT. The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review. Br J Psychiatry. 2022;221:603–12. Szücs A, Perry-Falconi MA, O'Brien EJ, Keilp JG, Bridge JA, Maier AB, Galfalvy H, Szanto K. Objective and subjective suicidal intent are differentially associated with attempt lethality based on age of onset of suicidal behavior. Sci Rep. 2025;15:5621. Troya MI, Babatunde O, Polidano K, Bartlam B, McCloskey E, Dikomitis L. and C. A. Chew-Graham. 2019. 'Self-harm in older adults: systematic review'. Br J Psychiatry, 214: 186–200. Tsuchida T, Takahashi M, Mizugaki A, Narita H, Wada T. Differences in acute outcomes of suicide patients by psychiatric disorder: Retrospective observational study. Med (Baltim). 2023;102:e35065. WHO. 2025. Suicide. In. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 21 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers invited by journal 20 Apr, 2026 Editor assigned by journal 20 Apr, 2026 Editor invited by journal 20 Apr, 2026 Submission checks completed at journal 17 Apr, 2026 First submitted to journal 17 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Doherty","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYNACNoYEMP2BgYGxgZl4LcwMjDNI1sLMA9JCSDH/7N6DDxjKbPL4pc8fk7Zts5NtYGc+gFeLxJ1zyQYM59KKJfuS2aRz25KNG5jZEvBbcyPHTIKx7XDihjPMIC0HEhuYeQzw6pC/kWP+A6RlP0iLJVgL/we8WgyAtjCAbeEBamGE2ILfXYY3cowlEs6lJc44w2xs2XMu2biNmQ2/w+Ru5Bh++FBmk9jfw/jwxo8yO9l+/sMP8FsDAgkQikUCRLIRVo8AzPi9PQpGwSgYBSMWAAChDECogJ0AvQAAAABJRU5ErkJggg==","orcid":"","institution":"University College Dublin","correspondingAuthor":true,"prefix":"","firstName":"Anne","middleName":"M.","lastName":"Doherty","suffix":""},{"id":627651717,"identity":"31e93d76-c5d4-4de4-a26d-9a175359c4f9","order_by":1,"name":"Geraldine McCarthy","email":"","orcid":"","institution":"University of Galway","correspondingAuthor":false,"prefix":"","firstName":"Geraldine","middleName":"","lastName":"McCarthy","suffix":""},{"id":627651718,"identity":"cdb3b4b2-7235-4ce2-af4a-a543518647a0","order_by":2,"name":"Katerina Kavalidou","email":"","orcid":"","institution":"National Suicide Research Foundation","correspondingAuthor":false,"prefix":"","firstName":"Katerina","middleName":"","lastName":"Kavalidou","suffix":""},{"id":627651719,"identity":"7be81ee8-b94e-4a72-b902-5b611bae35a8","order_by":3,"name":"Vincent Russell","email":"","orcid":"","institution":"Royal College of Surgeons in Ireland","correspondingAuthor":false,"prefix":"","firstName":"Vincent","middleName":"","lastName":"Russell","suffix":""},{"id":627651720,"identity":"c2431d12-d564-492e-9bcd-e5d52cda1e03","order_by":4,"name":"Michael J. Norton","email":"","orcid":"","institution":"Royal College of Surgeons in Ireland","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"J.","lastName":"Norton","suffix":""},{"id":627651721,"identity":"f7aced83-13f8-49cb-95f3-76fcd7cd3e6f","order_by":5,"name":"Fiona Hoare","email":"","orcid":"","institution":"University College Dublin","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Hoare","suffix":""}],"badges":[],"createdAt":"2026-04-10 15:53:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9381367/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9381367/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108029574,"identity":"458b5596-49de-42b3-b647-18e58a773072","added_by":"auto","created_at":"2026-04-28 15:42:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34076,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePresentations of people aged 60 and over with Self-Harm from 2018 to 2022, with gender breakdown\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9381367/v1/dc147ee9170199e826d75041.png"},{"id":108181456,"identity":"81202eac-c9c2-4c7e-be82-8643ebb5feb1","added_by":"auto","created_at":"2026-04-30 08:58:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":364729,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9381367/v1/c122d741-5692-4e73-9479-b1497af0e67d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Medically Serious Suicide Attempts in a national cohort of older people attending Emergency Departments with a suicidal crisis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eInternationally, it is estimated that over 727,000 people die by suicide each year, with over 14\u0026nbsp;million episodes of self-harm annually. (WHO \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Moran et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) In the UK\u0026rsquo;s NICE guidelines, self-harm is defined as \u003cem\u003e\u0026ldquo;intentional self-poisoning or injury, irrespective of the apparent purpose\u0026rdquo;.\u003c/em\u003e (NICE \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) This includes acts which may or may not be associated with suicidal intent, and those with a degree of ambivalence. Self-harm as a key risk factor for suicide is a major public health concern. Self-harm is not necessarily associated with suicidal plans, and is associated with a range of functions and motivations. However, notwithstanding the range of motivations for the person involved, it is associated with death by suicide, and is an important risk factor for suicide. (Bostwick et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Carroll, Metcalfe, and Gunnell \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eCharacteristics of severe self-harm\u003c/h3\u003e\n\u003cp\u003eWhile self-harm and suicidal ideation may occur in people without a diagnosed mental illness, they have been described in association with many mental illnesses. The most common diagnosis among those who die by suicide is depression, encompassing depressive episodes and recurrent depressive disorder. (Bruce et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) Self-harm has been found to be one of the most reliable factors associated with future death by suicide: about 40% of those who die by suicide have records of previous attempts. (Cavanagh et al. \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) It has been calculated that self-harm is associated with a greatly increased risk of suicide in the year following an attempt by a factor of 66. (Hawton, Zahl, and Weatherall \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) However, not all acts of self-harm convey the same risk. If we view suicidality as a spectrum that ranges from passive death wish all the way to suicide, with suicidal ideation and mild/ moderate/ severe self-harm in between, and with high severity self-harm adjacent to suicide, high severity self-harm may have more in common with suicide than other types of suicidal presentations. (Giner et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Mohan et al. \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) Medically serious suicide attempts (MSSA) or medically serious self-harm are defined as self-harm that would have been fatal without access to emergency care and that subsequently required hospitalisation for more than 24 hours in critical care, or surgery under general anaesthesia. (Levi-Belz and Beautrais \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) While there have been a small number of studies which have examined the characteristics of MSSA, none have examined this in older people.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSelf-harm in older people\u003c/h2\u003e \u003cp\u003eIn almost all countries, self-harm is more frequently seen in young people and adolescents, while older adults have the highest suicide rate. Among older US-based men, the incidence is 48.7/100,000 (which is more than four-fold the age-adjusted rate in the US of 11.1/100,000) and is higher again, with a rate of 140 per 100,000 among older males in rural regions of China (Conwell and Thompson \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Likewise, the definition of \"older people\" can vary somewhat between countries. Studies from the US defines older people\u0026rdquo; as those aged 65 years and some Chinese studies set the cut-off at 60 years (Conwell and Thompson \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Rates of death by suicide increase with age past the age of 60; there is evidence that age has the opposite impact on rates of self-harm, with a lowering incidence over time. Hawton and Harriss examined the lifetime incidence of suicide related to self-harm, and reported a high ratio of self-harm to suicide (200:1) in those aged under 20 years, but this ratio was much lower in older adults (10:1 in those over 60 years) (Hawton and Harriss \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). This phenomenon even applies to older people who died by suicide. In the context of both the elevated rate of suicide as a cause of death among older adults, and self-harm\u0026rsquo;s role as a key risk factor for suicide, identifying the characteristics of self-harm in this population is a clinical priority. Additionally, understanding the demographic and clinical factors associated with suicidal behaviours, along with patterns of engagement with services, is crucial for tailoring interventions and clinical services to meet their needs compassionately and effectively. Exmainig the variables associated with high-lethality self-harm can help us better identify those at highest risk, including individuals who present with MSSA.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eObjectives\u003c/h3\u003e\n\u003cp\u003eThis study aimed to identify the clinical and sociodemographic characteristics of older adults who present with higher severity self-harm, that meets the criteria for MSSA.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDesign \u0026amp; setting\u003c/h2\u003e \u003cp\u003eThis cohort study is based on a national dataset collected and maintained by the Irish Health Service Executive\u0026rsquo;s National Clinical Programme for Self-Harm and Suicide-related ideation (NCPSHI). Since 2010, the NCPSHI has ensured that all patients who present to the ED with suicidal ideation or self-harm receive a full biopsychosocial assessment promptly (HSE \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The NCPSHI has set the standards for both the biopsychosocial assessment and the following clinical management of people presenting to EDs with suicidal ideation or self-harm. The Clinical Nurse Specialists (CNSs) of the NCPSHI play a key role in coordinating data collection to monitor and evaluate programme outcomes, in addition to their clinical duties in performing clinical assessments. These data are anonymised upon entry into the NCPSHI electronic template, and this dataset includes all individuals seen in the ED, whether by CNSs and other members of the consultation-liaison psychiatry teams during working hours, or by on-call psychiatry clinicians outside core working hours (Hoare et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThis study is based on the years 2018\u0026ndash;2022, using a national dataset which comprises a complete five-year cohort of 72,810 presentations (HSE \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This data comprises anonymised information from Irish EDs serving adult patients. Data are de-identified at the point of submission and reflect the number of presentations and not the individuals presenting.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eVariables \u0026amp; measurement\u003c/h2\u003e \u003cp\u003eSociodemographic information is collected as part of the biopsychosocial assessments. Since 2018, age groups have been recorded under the following brackets: \u0026lt;19, 20\u0026ndash;29, 30\u0026ndash;39, 40\u0026ndash;49, 50\u0026ndash;59 and \u0026gt;\u0026thinsp;60. Other sociodemographic information collected includes ethnic background (as defined and categorised by Ireland\u0026rsquo;s Central Statistics Office), gender, employment status (collected since January 2020), and hospital. The dataset also includes clinical information regarding whether the individual presented with self-harm or ideation, lethality of self-harm act (since the beginning of 2020), details of suicidal thoughts (i.e. regarding suicide or self-harm), any substance use which may have contributed to the presentation, if medical treatment was required (whether the person required medical/surgical/ critical care admission for physical treatment of self-harm), and prior or current engagement with a mental health service (including if the individual is attending a statutory, voluntary or private service). In addition, the database holds information on the source of referral to the ED and on onward referral following assessment (including psychiatric admission and referral to a range of statutory services and voluntary agencies).\u003c/p\u003e \u003cp\u003eThe NCPSHI requires that the following suicide prevention interventions are completed and recorded for each presentation. These include, in addition, the completion og a biopsychosocial assessment, an emergency safety plan, the collection of a collateral history and, where possible, next-of-kin engagement in the development of a discharge plan. A summary letter is sent to the individual\u0026rsquo;s GP within one working day, and if appropriate, copied to the individual\u0026rsquo;s mental health service. The database records bridging or follow-up calls (within 72 hours of assessment), another key evidence-based suicide prevention intervention.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMedical lethality\u003c/em\u003e: In this dataset, two measures were used to assess lethality: the lethality measure from the dataset (limited to years 2020\u0026ndash;2022, a measure input by the clinical nurse specialist collecting the data at the site), and the need for medical admission as a proxy for medical seriousness or lethality: this latter group represents MMSA proper.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePower calculation\u003c/h3\u003e\n\u003cp\u003eAs this study was a full retrospective cohort study of a nationally provided service over five years, and included all presentations (n\u0026thinsp;=\u0026thinsp;72,810); a power calculation was not required. Older people represented a smaller subgroup (n\u0026thinsp;=\u0026thinsp;5,041).\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were input into SPSS and analysed to assess the characteristics of suicidality in the population aged over 60 years, using descriptive statistics, specifically chi-square tests. This study developed a multivariable model in order to explore the relationship between older age and MSSA, and controlled for confounding factors. We examined the relationship between MSSA and psychiatric admission using logistic regression and controlled for gender, year of presentation, co-occurring substance use, and medical admission. The significance level was set at 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis NCPSHI database comprised presentations of all people presenting with suicidal ideation and self-harm to EDs across Ireland for the years 2018 to 2022. The majority of those presentations were from people under 60 years of age (n=67,603), with 5,041 presentations from those aged over 60 (see Table 1). The number of presentations to EDs increased significantly from 2018 to 2022 in both age groups (over and under 60 years). However, the presentations of those aged over 60 years increased to a significantly higher degree (n = 1316, 26.1%) compared with those aged under 60 (n = 15351, 22.7%, p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eOverall, the number of older people attending EDs nationally with self-harm increased from 409 presentations in 2018 to 439 in 2020 (107% of the 2018 attendance). In the aftermath of the COVID-19 pandemic, the numbers continued to increase, with 528 presentations in 2022, 129% of the 2018 presentations. The increase was more marked in men (an increase of 138%) than in women (an increase of 123%), as illustrated in Figure 1.\u003c/p\u003e\n\u003cp\u003eThere were significant differences in self-harm proportions across age brackets. The highest proportions of self-harm were in the 20-29 age bracket (n=10,593, 29.7%, p\u0026lt;0.001), while the lowest proportions were in the group aged over 60 years (n=2,193, 6.1%, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eWhite Irish was overwhelmingly the most common ethnicity among presentations in both the under-60s and over-60s, representing a greater proportion of the over-60s: 85.2% vs 91.9%, p \u0026lt; 0.001. In all age groups, the most common method of self-harm was drug overdose, and this formed a significantly greater proportion of the over-60 age group: (n=1,471) 30.2% compared with (n=17,619) 27.3% in the under-60s, p\u0026lt;0.001 (Table 1). Presentations from those aged under 60 had a higher prevalence of drug use, compared to those over 60, who had a higher prevalence of alcohol use only. A higher proportion of those over 60 years were currently attending a mental health service; n = 1828, 38.1%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Clinical characteristics of people aged \u0026gt;60years compared with those aged under 60\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eyears\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal (n=72,644)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;60 (n=67,603)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt;60\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=5,041)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003cp\u003e(c\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Harm\u0026nbsp;\u003c/strong\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No (suicide-related \u0026nbsp;ideation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35695 (51.5)\u003c/p\u003e\n \u003cp\u003e33625 (48.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e33502 (52)\u003c/p\u003e\n \u003cp\u003e30952 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2193 (45.1)\u003c/p\u003e\n \u003cp\u003e2673 (54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(86.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Self Harm\u0026nbsp;\u003c/strong\u003eCutting\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Attempted Drowning\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Drug and Alcohol overdose\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Drug Overdose\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Attempted Hanging\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Jumping from a height\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Shooting\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Multiple methods\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Attempted suffocation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8243 (11.9)\u003c/p\u003e\n \u003cp\u003e811 (1.2)\u003c/p\u003e\n \u003cp\u003e2052 (3)\u003c/p\u003e\n \u003cp\u003e19090 (27.5)\u003c/p\u003e\n \u003cp\u003e2126 (3.1)\u003c/p\u003e\n \u003cp\u003e329 (0.5)\u003c/p\u003e\n \u003cp\u003e21 (0)\u003c/p\u003e\n \u003cp\u003e1172 (1.7)\u003c/p\u003e\n \u003cp\u003e18 (0)\u003c/p\u003e\n \u003cp\u003e1833 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8006 (12.4)\u003c/p\u003e\n \u003cp\u003e739 (1.1)\u003c/p\u003e\n \u003cp\u003e1952 (3)\u003c/p\u003e\n \u003cp\u003e17619 (27.3)\u003c/p\u003e\n \u003cp\u003e2060 (3.2)\u003c/p\u003e\n \u003cp\u003e309 (0.5)\u003c/p\u003e\n \u003cp\u003e18 (0)\u003c/p\u003e\n \u003cp\u003e1117 (1.7)\u003c/p\u003e\n \u003cp\u003e17 (0)\u003c/p\u003e\n \u003cp\u003e1665 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e237 (4.9)\u003c/p\u003e\n \u003cp\u003e72 (1.5)\u003c/p\u003e\n \u003cp\u003e100 (2.1)\u003c/p\u003e\n \u003cp\u003e1471 (30.2)\u003c/p\u003e\n \u003cp\u003e66 (1.4)\u003c/p\u003e\n \u003cp\u003e20 (0.4)\u003c/p\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003cp\u003e55 (1.1)\u003c/p\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003cp\u003e168 (3.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(479.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubstance Use\u0026nbsp;\u003c/strong\u003eAlcohol and Drugs\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Alcohol only\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Drugs only\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No drugs or alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9318 (12.8)\u003c/p\u003e\n \u003cp\u003e16114 (22.2)\u003c/p\u003e\n \u003cp\u003e6352 (8.7)\u003c/p\u003e\n \u003cp\u003e40860 (56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9227 (13.6)\u003c/p\u003e\n \u003cp\u003e14781 (21.9)\u003c/p\u003e\n \u003cp\u003e6275 (9.3)\u003c/p\u003e\n \u003cp\u003e37320 (55.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e91 (1.8)\u003c/p\u003e\n \u003cp\u003e1333 (26.4)\u003c/p\u003e\n \u003cp\u003e77 (1.5)\u003c/p\u003e\n \u003cp\u003e3540 (70.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(1068.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttending mental health team\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo/Unknown\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42713 (63.4)\u003c/p\u003e\n \u003cp\u003e24697 (36.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39743 (63.5)\u003c/p\u003e\n \u003cp\u003e22869 (36.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2970 (61.9)\u003c/p\u003e\n \u003cp\u003e1828 (38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.029\u003c/p\u003e\n \u003cp\u003e(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReferred to ED by\u0026nbsp;\u003c/strong\u003eMental health team\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;General practitioner\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Police\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e649 (0.9)\u003c/p\u003e\n \u003cp\u003e8695 (12)\u003c/p\u003e\n \u003cp\u003e3959 (5.5)\u003c/p\u003e\n \u003cp\u003e59022 (81.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e576 (0.9)\u003c/p\u003e\n \u003cp\u003e7984 (11.9)\u003c/p\u003e\n \u003cp\u003e3790 (5.6)\u003c/p\u003e\n \u003cp\u003e54950 (81.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73 (1.5)\u003c/p\u003e\n \u003cp\u003e711 (14.1)\u003c/p\u003e\n \u003cp\u003e169 (3.4)\u003c/p\u003e\n \u003cp\u003e4072 (81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(259.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAssessment Location\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eED\u003c/p\u003e\n \u003cp\u003eMedical/Surgical/ICU\u003c/p\u003e\n \u003cp\u003eNot assessed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e58379 (80.4)\u003c/p\u003e\n \u003cp\u003e6654 (9.2)\u003c/p\u003e\n \u003cp\u003e7589 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54633 (80.8)\u003c/p\u003e\n \u003cp\u003e5711 (8.5)\u003c/p\u003e\n \u003cp\u003e7239 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3746 (74.3)\u003c/p\u003e\n \u003cp\u003e943 (18.7)\u003c/p\u003e\n \u003cp\u003e350 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(627.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReasons not assessed\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eLeft ED before assessment completed\u003c/p\u003e\n \u003cp\u003eRIP\u003c/p\u003e\n \u003cp\u003eTransferred to another site\u003c/p\u003e\n \u003cp\u003eNot recorded\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5780 (76.2)\u003c/p\u003e\n \u003cp\u003e65 (0.9)\u003c/p\u003e\n \u003cp\u003e1592 (21)\u003c/p\u003e\n \u003cp\u003e153 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5537 (76.5)\u003c/p\u003e\n \u003cp\u003e55 (0.8)\u003c/p\u003e\n \u003cp\u003e1503 (20.8)\u003c/p\u003e\n \u003cp\u003e144 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e243 (69.2)\u003c/p\u003e\n \u003cp\u003e10 (2.8)\u003c/p\u003e\n \u003cp\u003e89 (25.4)\u003c/p\u003e\n \u003cp\u003e\u0026lt;10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(24.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubsequent admission to psychiatry\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54103 (83.2)\u003c/p\u003e\n \u003cp\u003e10951 (16.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50565 (83.8)\u003c/p\u003e\n \u003cp\u003e9799 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3538 (75.4)\u003c/p\u003e\n \u003cp\u003e1152 (24.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(215.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNext referrals\u0026nbsp;\u003c/strong\u003eSpecialist MHS\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e27245 (50.9)\u003c/p\u003e\n \u003cp\u003e26331 (49.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25387 (50.7)\u003c/p\u003e\n \u003cp\u003e24678 (49.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1858 (52.9)\u003c/p\u003e\n \u003cp\u003e1653 (47.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003cp\u003e(7036.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to admission/discharge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026lt;6 hours\u003c/p\u003e\n \u003cp\u003e\u0026lt;9 hours\u003c/p\u003e\n \u003cp\u003e\u0026gt;9 hours\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42416 (67.8)\u003c/p\u003e\n \u003cp\u003e10321 (16.5)\u003c/p\u003e\n \u003cp\u003e9819 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39650 (68.2)\u003c/p\u003e\n \u003cp\u003e9612 (16.5)\u003c/p\u003e\n \u003cp\u003e8847 (15.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2766 (62.2)\u003c/p\u003e\n \u003cp\u003e709 (15.9)\u003c/p\u003e\n \u003cp\u003e972 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(138.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003eConsistent with the methodology of the National Clinical Programme for Self-Harm and Suicide-Related ideation and filed with less than 10 presentations is presented as \u0026lt;10.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen the relationship between age and lethality was examined, two measures were used to assess lethality: the lethality measure from the dataset (limited to years 2020-2022) and the need for medical admission as a proxy for medical seriousness or lethality: this group representing MMSA proper. \u0026nbsp;Lethality of attempt in the over 60s was significantly more likely to be rated as moderate or high compared with those under 60 years. Over one-fifth (20.7%, n=216) of self-harm in those over 60 was rated as being of high lethality, nearly double the proportion \u0026nbsp;(11.8%; n=1761) in those under 60, p\u0026lt;0.001. People aged over 60 years were significantly more likely to be assessed on a medical or surgical ward or in the ICU (n=943, 18.7%) compared with the under-60-year cohort (n=5711, 8.5%; p\u0026lt;0.001). When we examined the relationship between the objective measure of lethality (need for admission for medical/ surgical treatment) with the subjective measure which was input into the database by the clinicians at the sites (only available for a portion of the sample), there were significant differences between the two groups on bivariate analysis, both in the group as a whole and in those aged over 65 years (table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 2: Measures of lethality in the whole population and in those aged over 60 years\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMedically treated in ED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdmitted to a medical /surgical/ critical care ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003cp\u003e(c\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eLethality measure input by coder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN= 16,009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN= 13,209\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN= 2800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7,956 (49.7)\u003c/p\u003e\n \u003cp\u003e6,076 (38)\u003c/p\u003e\n \u003cp\u003e1,977 (12.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7356 (92.5)\u003c/p\u003e\n \u003cp\u003e4597 (75.7)\u003c/p\u003e\n \u003cp\u003e1256 (63.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e600 (21.4)\u003c/p\u003e\n \u003cp\u003e1479 (52.8)\u003c/p\u003e\n \u003cp\u003e721 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(1236.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOver 60s\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN= 1,043\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN= 711\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eN= 332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e402 (38.6)\u003c/p\u003e\n \u003cp\u003e425 (40.7)\u003c/p\u003e\n \u003cp\u003e216 (20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e323 (45.5)\u003c/p\u003e\n \u003cp\u003e269 (37.8)\u003c/p\u003e\n \u003cp\u003e119 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e79 (23.8)\u003c/p\u003e\n \u003cp\u003e156 (47)\u003c/p\u003e\n \u003cp\u003e97 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003cp\u003e(49.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eThis table compares measures of lethality in the whole population and in those aged over 60 years for whom both measures of lethality are available, the measure inputted by the coder (2020-2022) and the proxy measure: need for medical treatment as an inpatient (n=16,009)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe patients aged 60 years and over were more likely to be admitted to a mental health inpatient unit (n=1152, 24.6%) compared with those aged under 60 (n=9799, 16.2%), p\u0026lt;0.001. The ratio of low to high lethality self-harm was 4.4:1 in the under-60s and 1.9:1 in the over-60s, using the measure in the database, and the ratio of ED-treated to medically admitted was 9.6:1 in the under-60s and 3.9:1 in the over-60s.\u003c/p\u003e\n\u003cp\u003eOn logistic regression, the association between older age and MSSA (using the proxy measure of admission to a medical/ surgical/ critical care bed) was statistically significant with an Odds Ratio (OR) of 1.32; CI:1.244-1.399). This remained significant after controlling for gender, ethnicity, attending mental health services and substance use. (OR 1.23; CI:1.157-1.305; p\u0026lt;0.001: see table 3). Female gender was similarly significantly associated with MSSA (OR 1.82; CI:1.763-1.878; p\u0026lt;0.001), as was active substance use \u0026nbsp; (OR 0.7; CI:0.679-0.723; p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 3: Logistic regression examining the relationship between higher lethality self-harm and age\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"557\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOdds Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConfidence interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge (under v over 60 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.244-1.399\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge (under v over 60 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.157-1.305\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.763-1.878\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.022-1.129\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSubstance use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.679-0.723\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAttending mental health services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.948-1.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eModel 3 (over 65 years only)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.791-2.264\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEthnicity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.006-1.612\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSubstance use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.699-0.901\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAttending mental health services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.208\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.958-1.219\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eModels 1 and 2 show the relationship between higher lethality self-harm (dependent variable) and age; and Model 3 shows the variables associated with high lethality self-harm in those aged over 60 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen we ran this model in those aged over 60 years only (removing age as a variable, but retaining gender, ethnicity, attending mental health services and substance use), female gender was significantly associated with MSSA (OR 2.01; CI:1.791-2.264; p\u0026lt;0.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur results illustrate the significant differences in the older individuals who present to Irish EDs with MSSA or high lethality self-harm compared with younger people, where previously a paucity of data existed. This study reported a year-on-year increase in the number of older people attending the ED with self-harm between 2018 and 2022. It also found\u0026nbsp;that people aged over 60 years attending EDs with self-harm and suicidal ideation represented a small population compared with younger people (6.1% of the total). However, self-harm episodes were significantly more likely to be graded “moderate” or \"high” lethality. One-fifth of the self-harm in those over 60 years was rated as ‘high lethality’.\u003c/p\u003e\n\u003cp\u003ePeople aged over 60 years were more than twice as likely to require admission to a medical, surgical or critical care ward compared with those aged under 60. This may be seen as a proxy measure for medical lethality. \u0026nbsp;Older age was strongly associated with medical admission on logistic regression after controlling for other variables such as gender, age, ethnicity, substance use and previous attendance at mental health services. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOlder people were significantly more likely to have pre-existing contact with mental health services or to have been referred to the ED by a health professional. In addition, older people were significantly more likely to require admission to a psychiatric ward, which indicates a higher degree of psychiatric illness in this population. This may also reflect barriers to access to services, for example, while all persons aged over 70 years have free primary healthcare, this is not the case for those aged under 70, where it is means-tested, which means that about 2/3 of people there have a cost associated with attending their primary healthcare provider.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese findings are consistent with the literature, which shows that older people are overrepresented among those admitted with more medically serious self-harm. This is an important population to identify, as there is evidence that people who experience medically serious self-harm have much in common with those who die by suicide. (Beautrais 2001) These findings are reflected in the proportion of presentations that require admission for medical or surgical treatment of their injuries, as well as in the nurse-rated lethality score. It is worth noting that critical care admission for any cause is associated with an elevated suicide risk. Fernando et al, in their study of 423,060 people who had required critical care admission, reported an increased rate of both suicide and self-harm, with hazard ratios of 1.15 and 1.22, respectively. (Fernando et al. 2021) While this study reported a lower mean age in those who had an episode of self-harm or suicide following a critical care admission, these outcomes were associated with higher rates of premorbid mental ill-health. However, this study did not specify whether any of the included patients had a critical care admission precipitated by an act of self-harm. (Fernando et al. 2021) Given that psychiatric admission within the past 3 months is associated with suicide rates up to 100 times the population rates, the subgroup of patients requiring critical care admission due to self-harm is likely to have significantly elevated suicide risk. (Meehan et al. 2006; Chung et al. 2017)\u003c/p\u003e\n\u003cp\u003eThe ratio of low to high lethality of self-harm of 1.9:1 compared with in those aged under 60, where it is 4.4:1, suggests that, in general, episodes of self-harm in older people are more frequently associated with a higher level of medical lethality. While this study does not allow a direct comparison with suicide rates, the differing ratios in self-harm between those aged above and below 60 years suggest there is a difference in the function of self-harm in this population. These may be different points on a spectrum ranging from suicidal ideation through to death by suicide as conceptualised by Mohan et al. (Mohan et al. 2020). This reflects a similar pattern to that described by Hawton and Harriss, who reported a much higher ratio of self-harm to suicide, of 10:1 in individuals aged 60 years. (Hawton and Harriss 2008)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the database does not capture psychiatric diagnoses, the significantly higher proportions of older people requiring psychiatric admission may be seen to represent a greater burden of mental illness in this population. Di Lorenzo et al likewise reported that a greater proportion of retired persons required psychiatric hospitalisation for self-harm compared with other reasons for admission (4.7% v 3.9%). (Di Lorenzo et al. 2024) An Italian study of older people who accessed psychiatry admission for self-harm reported that the majority (62.3%) had never had a previous admission, and 46.4% were not attending mental health services at the time of the self-harm, which precipitated the admission: higher than the 38.1% attending in this study. (Gramaglia et al. 2021)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is conflicting evidence from the literature regarding the impact of the COVID-19 pandemic on older people and medically serious self-harm, with the systematic review by Pathiranthna and colleagues reporting elevated rates in older people associated with pre-existing mental illness and financial difficulties identified as contributing factors. (Pathirathna et al. 2022) On the other hand, studies by Corbe and colleagues and by Beneria and colleagues reported that younger people were disproportionately affected by self-harm in France and Spain, respectively (Beneria et al. 2024; Corbé et al. 2023). Our study showed a steady increase in older people’s attendance at EDs with self-harm and suicidal ideation pre-pandemic over the years \u0026nbsp;2018 - 2020. The numbers continued to increase further in the aftermath of the pandemic. This suggests unmet need in the community, and perhaps an increased willingness to seek help, unexpected in the context of the focus on “cocooning” older adults during this pandemic. Overall, these findings are consistent with the literature, suggesting that, in the midst of the pandemic, there was no major increase in presentations; however, this increase was more likely to occur after the initial crisis of the pandemic. (Steeg et al. 2022; McIntyre et al. 2021). One single-site study from Japan, which examined the medical lethality of patients presenting to an urban hospital, reported significantly elevated lethality among older men (Tsuchida et al. 2023). \u0026nbsp;Our findings are consistent with those reported by Szucs et al, which found that medically serious self-harm was associated with older age. (Szücs et al. 2025)\u0026nbsp; The high rates of critical care admissions for older adults are similarly surprising given the pressure on critical care beds in the pandemic. \u0026nbsp;Cai et al reported in their systematic review that there was a significantly elevated suicide rate among older people (Cai et al. 2022). One systematic review, which examined high medical lethality self-harm in older people, did not find any significant association between severity of lethality and age or gender. (Barker, Oakes-Rogers, and Leddy 2022). The prevalence of higher lethality self-harm attempts in older people attending Irish EDs suggests an urgent need to identify and understand the characteristics of self-harm in this population. This information is key to developing treatments and responsive (even proactive) services that meet the specific needs of this high-risk group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe impact of gender on medically serious self-harm suggests that women are more likely to require a medical admission for self-harm, which indicates that older women present with MSSA at twice the rate of men, despite having lower rates of suicide. This is consistent with existing evidence, which suggests that women have higher rates of more serious episodes of self-harm as they age. (Clements et al. 2025; Troya et al. 2019)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrength and Limitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe strengths of this paper include the utilisation of a national data source of a cohort presenting to EDs with suicidal ideation and /or self-harm to examine the characteristics of older adults. The comparison between older and younger people who present with self-harm identified key differences in sociodemographic and clinical characteristics between the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe retrospective nature of the register is a limitation of the study. However, the population studied is a complete clinical sample. It is further limited in the presentation-based rather than individual-based nature of the dataset; therefore, repeated presentations of individuals are not captured. The lethality measure used for multivariable analysis, utilised the need for medical/surgical/ critical care admission as a proxy for a more direct method of assessing lethality. \u0026nbsp;While this is an Irish national database, the findings are likely generalisable to other international settings where emergency care and all mental healthcare is free at the point of access.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur results indicate significant differences in older people compared with younger people who attend the ED with suicidal ideation or high lethality self-harm. The higher prevalence of MSSA amongst the older cohort makes it a clinical priority to understand the variables associated with increased risk. The higher psychiatric admission rates identified in this cohort are important in resource allocation and service development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is a need for further work to better understand the characteristics, motivations and clinical needs of older adults who attend the ED with suicidal ideation or self-harm, especially MSSA. Specifically, further information regarding the medical lethality and the perceived lethality, along with details of the types of difficulties, especially mental illness, which precipitated the event, would greatly enhance our understanding of this population.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors thank the\u0026nbsp;National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland for allowing access to their data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement:\u003c/strong\u003e A.M.D. served as lead for conceptualisation, formal analysis, visualisation and writing. F. H. served in a supporting role for conceptualisation, formal analysis and writing. K.K., V.R., G.McC., and M.N. contributed equally to investigation and data curation and contributed equally to writing (review and editing).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Considerations:\u003c/strong\u003e The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2013. All procedures involving human subjects/patients were approved by the Clinical Research Ethics Committee of University College Dublin LS-LR-22-167.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate:\u003c/strong\u003e Not applicable. The authors assert that the anonymised registry was obtained from the\u0026nbsp;National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland.\u0026nbsp;As the data represent presentations, and not individuals, and were fully anonymised and collected as part of routine care, individual-level consent was not required, and the requirement for informed consent was waived by the Ethics Committee (Clinical Research Ethics Committee of University College Dublin\u0026nbsp;LS-LR-22-167).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of conflicting interest:\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u003c/strong\u003e This research received no specific grant from any funding agency, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e: \u0026nbsp;The data that support the findings of this study are available from the National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland. Restrictions apply to the availability of these data, which were used under licence for this study. Data are available with the permission of the National Clinical Programme for Self-Harm and Suicide-related Ideation, Health Service Executive, Ireland.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarker J, Oakes-Rogers S, Leddy A. What distinguishes high and low-lethality suicide attempts in older adults? A systematic review and meta-analysis. J Psychiatr Res. 2022;154:91\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeautrais AL. Suicides and serious suicide attempts: two populations or one? Psychol Med. 2001;31:837\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeneria A, Marte L, Quesada-Franco M, Garc\u0026iacute;a-Gonz\u0026aacute;lez S, Restoy D, P\u0026eacute;rez-Galbarro C, Santesteban-Echarri O, Ramos R, Ramos-Quiroga JA, Braquehais MD. 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Assessing the characteristics of suicidal ideation and self-harm in a national older adult population attending emergency departments across Ireland: cohort study protocol. BMJ Open. 2024;14:e087797.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHSE. 2022. National Clinical Programme for Self-Harm and Suicide-related Ideation. In, edited by National Clinical Programme for Self Harm and Suicide Related Ideation \u0026ndash; Implementation Advisory Group. Dublin: HSE, CPsychI, ICGP.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevi-Belz Y, Beautrais A. 'Serious Suicide Attempts' Crisis. 2016;37:299\u0026ndash;309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcIntyre A, Tong K, McMahon E, Doherty AM. COVID-19 and its effect on emergency presentations to a tertiary hospital with self-harm in Ireland. Ir J Psychol Med. 2021;38:116\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeehan J, Kapur N, Hunt IM, Turnbull P, Robinson J, Bickley H, Parsons R, Flynn S, Burns J, Amos T, Shaw J, Appleby L. Suicide in mental health in-patients and within 3 months of discharge. National clinical survey. Br J Psychiatry. 2006;188:129\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohan C, Tembo V, McNicholas B, Doherty AM. 2020. 'Defining high risk by clinical lethality: The different characteristics and management of the survivors of serious self-injury admitted to critical care, compared with lower lethality self-injury'. Gen Hosp Psychiatry.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoran P, Chandler A, Dudgeon P, Kirtley OJ, Knipe D, Pirkis J, Sinyor M, Allister R, Ansloos J, Ball MA, Chan LF, Darwin L, Derry KL, Hawton K, Heney V, Hetrick S, Li A, Machado DB, McAllister E, McDaid D, Mehra I, Niederkrotenthaler T, Nock MK, O'Keefe VM, Oquendo MA, Osafo J, Patel V, Pathare S, Peltier S, Roberts T, Robinson J, Shand F, Stirling F, Stoor JPA, Swingler N, Turecki G, Venkatesh S, Waitoki W, Wright M, Yip PSF, Spoelma MJ, Kapur N, Christensen. Lancet. 2024;404:1445\u0026ndash;92. 'The Lancet Commission on self-harm'.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNICE. Self-harm: assessment, management and preventing recurrence. Guideline number NG225. In. London: National Institute for Health and Care Excellence; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePathirathna ML, Nandasena H, Atapattu A, Weerasekara I. Impact of the COVID-19 pandemic on suicidal attempts and death rates: a systematic review. BMC Psychiatry. 2022;22:506.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteeg S, John A, Gunnell DJ, Kapur N, Dekel D, Schmidt L, Knipe D, Arensman E, Hawton K, Higgins JPT, Eyles E, Macleod-Hall C, McGuiness LA, Webb RT. The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review. Br J Psychiatry. 2022;221:603\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSz\u0026uuml;cs A, Perry-Falconi MA, O'Brien EJ, Keilp JG, Bridge JA, Maier AB, Galfalvy H, Szanto K. Objective and subjective suicidal intent are differentially associated with attempt lethality based on age of onset of suicidal behavior. Sci Rep. 2025;15:5621.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTroya MI, Babatunde O, Polidano K, Bartlam B, McCloskey E, Dikomitis L. and C. A. Chew-Graham. 2019. 'Self-harm in older adults: systematic review'. Br J Psychiatry, 214: 186\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsuchida T, Takahashi M, Mizugaki A, Narita H, Wada T. Differences in acute outcomes of suicide patients by psychiatric disorder: Retrospective observational study. Med (Baltim). 2023;102:e35065.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. 2025. Suicide. In.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Self-harm: Suicide, Suicidal ideation, Gerontology, Emergency treatment.","lastPublishedDoi":"10.21203/rs.3.rs-9381367/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9381367/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInternationally, there are higher rates of death by suicide among older adults, but self-harm is less common in this population. Medically Serious Suicide Attempts (MSSA) represent the most serious and potentially fatal self-harm presentations, but little is known about this in older people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to examine the characteristics associated with MSSA among older adults presenting to emergency departments (EDs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study reports a cohort of people in Ireland presenting with suicide-related ideation and self-harm to EDs from 2018 to 2022. The data comes from database of the National Clinical Programme for Self-Harm and Suicide-related Ideation and includes 72,810 clinical presentations. The characteristics associated with MSSA were examined in those aged over 60.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study found that nearly twice as many episodes of self-harm in people aged over 60 years were graded “moderate” or \"high” lethality, with one-fifth (20.3%, n=219) of attempts of those over 60 were rated as high lethality (11.6% under 60: p\u0026lt;0.001). People aged over 60 were more than twice as likely to require admission to a medical, surgical or critical care ward (n=943, 18.7%) compared with those under 60 (n=5711, 8.5%; p\u0026lt;0.001). The association between older age and high self-harm lethality remained significant after controlling for gender, ethnicity and substance use (Odds Ratio 1.23; CI: CI:1.157-1.305).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe higher proportion of MSSA amongst the older cohort, taken in the context of the higher suicide rates in this group, highlights the urgent need to understand better the variables associated with increased risk.\u003c/p\u003e","manuscriptTitle":"Medically Serious Suicide Attempts in a national cohort of older people attending Emergency Departments with a suicidal crisis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-28 15:41:57","doi":"10.21203/rs.3.rs-9381367/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-21T22:01:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6413850123925695555856438524577084814","date":"2026-04-20T12:04:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-20T08:13:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-20T08:04:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-20T07:07:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-17T20:08:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2026-04-17T17:56:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"826e7c21-fc50-407f-8253-dad76481fc54","owner":[],"postedDate":"April 28th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T15:41:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-28 15:41:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9381367","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9381367","identity":"rs-9381367","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}