Self-poisoning by older Australians

Improving mental care for people over 65 must be a priority

In this issue of the MJA, important data on self-poisoning by older people presenting to the Hunter Area Toxicology Service (HATS) over a 26-year period are reported.1 It is firstly to be recognised that these data are the result of the enormous effort involved in maintaining a database over a period of that length. They are clearly of interest to specialists in the field of toxicology, but the data will also attract much broader interest. Suicide rates among men in Australia aged 85 or more were the highest for any age group throughout the period of study.2 Further, self-poisoning remains one of the most common methods employed. This report is therefore very interesting, and may provide clues about how to respond to this major, but often hidden, public health challenge.

The study by Pillans and co-authors found that only 3.6% of all toxicology presentations to HATS were by people over 65.1 However, the importance of this group of patients lies in the fact that overdoses in older people were associated with longer admission times, and greater likelihood of admission to an intensive care unit, need for artificial ventilation, and death (3.8% of older patients died, compared with 0.6% of those under 65). These findings are consistent with long term experience that suicide attempts by older people are more likely to end in death than those of younger people.3,4 This all suggests that overdoses in older people are a very important area for intervention. This need is further underlined by the acknowledgement of the study authors that they were unable to include overdoses that resulted in death without admission to hospital. The relatively high lethality of overdoses in older people, together with available community data, suggests the number of such deaths is not small.

This all raises the question as to what can be done in response to this important problem. The first step, undertaken by the authors, is to highlight its significance. It is noteworthy that, despite the size of the problem, it has received relatively little public attention, with almost an unspoken suggestion that suicide is a life choice or a consequence of ageing. Yet, as the authors acknowledge, most older patients admitted to hospital after self-poisoning have a history of mental illness, as also noted by other investigators.3 Unfortunately, the data available to Pillans and his colleagues were limited to retrospective information about a history of suicide attempts (32% of admitted older patients), psychiatric illness (38%), admission to hospital for a mental health problem (28%), or drug and alcohol use (23%). While this suggests that most older people admitted to hospital after self-poisoning had at least one of these risk factors, each of these numbers was lower than for patients under 65. This is somewhat surprising, apart from the differences in rates of substance misuse; whether it is related to a generational reluctance to acknowledge problems or to seek mental health care is not clear, or it may underline how frequent these problems are in younger patients. Assessments of current psychopathology in these patients, including depression and anxiety, were not available, and it might reasonably be suspected that most of the admitted patients, regardless of age, would present evidence of mental health problems.

So where is the public awareness campaign about the mental health of older people? Nothing is currently seen or heard.5 Despite the growth of our older population,6 public attention has been limited, despite a clear increase in the volume of campaigns about mental health in general, including those raising awareness of suicide.7 It is unclear why so little attention is paid to a group that is at such high risk.

Such a campaign could highlight that depression and other mental health problems are not a sine qua non of ageing, that they are diagnosable and treatable in the vast majority of cases, and that the stigma attached to receiving such assistance should be reduced for older people as it has been for other age groups. Such a campaign would be timely, as major reforms are currently being undertaken in the mental health sector, including new roles for primary health care networks.8 Most care for older people with disorders such as major depression is currently provided as part of primary care, and general practitioners deserve all the support possible in this sometimes daunting task. In this regard, it is noteworthy that the proportion of spending in the Better Access to Mental Health Care scheme for those over 60 is only 8%.9 If the problem is granted appropriate priority, we can hopefully change the sad but hidden situation highlighted by Pillans and his co-authors.