What is the best course of treatment for a patient with Self-Injurious (SI) and Self-Harm (SH) behaviors?

Treatment of Self-Injurious and Self-Harm Behaviors

All patients presenting with self-injurious (SI) and self-harm (SH) behaviors require an immediate comprehensive psychosocial assessment by a mental health clinician to identify specific needs and risk/protective factors, followed by evidence-based psychotherapy—with Dialectical Behavior Therapy for Adolescents (DBT-A) showing the strongest evidence for young people, and Mentalisation-Based Therapy (MBT) or individual Cognitive Behavioral Therapy (CBT) for adults. 1, 2

Immediate Assessment and Safety Planning

Every patient must receive a comprehensive psychosocial assessment that includes:

• Thorough evaluation of self-harm thoughts: frequency, intensity, presence of suicidal ideation, specific plans, access to means, and intent 3, 4
• Risk stratification: Strong suicidal intent, high lethality of method, precautions against discovery, and psychiatric illness indicate high suicide risk 5
• Formulation of contributing factors and development of a risk management plan 1
• Restriction of access to potential means of self-harm as long as thoughts persist 3

Critical caveat: One-quarter of young people presenting to emergency departments after self-harm do not receive these assessments—this represents a missed opportunity for appropriate intervention 1

Age-Specific Treatment Approaches

For Young People (Adolescents and Young Adults)

Dialectical Behavior Therapy for Adolescents (DBT-A) is the first-line psychotherapy when available, as it specifically targets emotion dysregulation and self-injury 1, 4

However, DBT-A is resource-intensive and unlikely to be realistic for most young people 1. When DBT-A is not feasible:

• Cognitive Behavioral Therapy adapted to the adolescent context may provide benefit 1
• Group-based emotion-regulation psychotherapy may reduce repetition of self-harm (OR 0.34,95% CI 0.13 to 0.88) 2
• Brief, single-encounter interventions (safety planning, care coordination) may be effective in emergency department settings 1
• Regular follow-up telephone contact over the post-discharge period may be effective 1

Essential treatment components across all modalities:

• Pay attention to the therapeutic relationship 1
• Involve the family wherever possible 1
• Implement structured problem-solving approaches to address current stressors 3
• Mobilize social support from family, friends, and community resources 3

For Adults

Mentalisation-Based Therapy (MBT) is the highest-quality evidence for reducing self-harm repetition in adults (OR 0.35,95% CI 0.17 to 0.73; high-certainty evidence from a single trial) 2

Individual CBT-based psychotherapy may reduce repetition of self-harm, particularly at longer follow-up time points (6- and 12-months), though evidence at post-intervention is less certain (OR 0.35,95% CI 0.12 to 1.02; low certainty evidence) 2

Dialectical Behavior Therapy (DBT) may lead to a slightly lower rate of self-harm repetition (66.0% vs 68.2%), though the absolute effect remains uncertain 2

Pharmacological Management

Pharmacotherapy is NOT recommended solely for the prevention of self-harm in young people 1

For adults, pharmacological agents should only be used for their indication for specific psychiatric disorders (e.g., antidepressants for concurrent depression), not specifically for self-harm prevention 1

Important medication considerations:

• Evaluate appropriateness of benzodiazepines (e.g., clonazepam), which should be used cautiously as they could be a potential means of self-harm 3
• If depression is moderate-to-severe, ensure SSRI dosing is optimized 4
• Note that OCD may require higher SSRI doses than depression alone 4

Common pitfall: To date, there have been no published trials of pharmacological agents specifically for prevention of self-harm/suicide in young people, and older agents tested in adults show no evidence of benefit for self-harm or suicide endpoints 1, 2

Differential Diagnosis Considerations

Self-harm is not a single clinical entity—it occurs across various psychiatric syndromes with wide-ranging psychopathology 6, 7:

• Major Depressive Disorder is the most common complication and strongly associated with self-harm 4
• Anxiety disorders, substance abuse are common risk factors 5
• Body Dysmorphic Disorder: approximately half of young people with BDD report self-harm 4
• OCD with harm obsessions: self-harm to "test" obsessional fears would be extremely unusual and should raise concern for misdiagnosis 4
• Non-suicidal self-injury disorder may serve emotion regulation functions unrelated to other diagnoses 4

Screen explicitly for comorbid conditions using standardized measures (PHQ-9 for adolescents, Beck Depression Inventory) at every clinical encounter 4

Follow-Up and Monitoring

Establish regular contact through:

• Frequent follow-up appointments to monitor treatment response 3
• Telephone calls, home visits, or scheduled appointments 3
• Screen for suicidal ideation, self-harm urges, and safety at every session 4
• Monitor for repeat self-harm, which is common and indicates need for treatment intensification 4

More than 5% of people seen at hospital after self-harm will have committed suicide within 9 years, highlighting the critical importance of ongoing monitoring 5

Staff Training and Service Delivery

Negative experiences of clinical services may perpetuate a cycle of self-harm 1. Therefore:

• Provide training to ensure all clinical staff treat patients in a person-centered and compassionate manner 1
• Provide easy access to immediate mentoring and supervision of emergency department staff 1
• Consider dedicating a separate area within the ED to triage and assess these presentations 1

Critical Pitfalls to Avoid

• Do not dismiss self-harm thoughts in older adults—this population may be at higher risk for completed suicide 3
• Do not assume absence of a plan means low risk—continue thorough assessment and monitoring 3
• Do not minimize mild self-injury—even minor self-harm significantly increases suicide risk 4
• Do not delay intervention waiting for "stabilization"—self-harm requires prompt, specific intervention 4
• Do not rely solely on medication adjustments without addressing psychosocial factors 3
• Avoid polypharmacy—try one medication class thoroughly before switching 8