Are any medications helpful for patients experiencing self-harm, particularly those with underlying mental health conditions such as depression, anxiety, or borderline personality disorder?

Medications for Self-Harm: Evidence-Based Recommendations

Pharmacotherapy is NOT recommended solely for the prevention of self-harm or suicide in young people or adults—medications should only be used when indicated for specific underlying psychiatric disorders such as depression, anxiety, or borderline personality disorder. 1, 2

Primary Treatment Approach: Non-Pharmacological First

The most recent high-quality guidelines emphasize that psychotherapy, not medication, is the treatment of choice for self-harm behavior:

• Dialectical Behavior Therapy adapted for adolescents (DBT-A) shows the most promise for reducing self-harm repetition (30% vs 43% in controls), though it requires intensive resources and experienced clinicians 1
• Cognitive Behavioral Therapy adapted to the adolescent context may benefit some patients 1
• Structured problem-solving approaches should be implemented for persons with acts of self-harm in the past year 1
• Regular contact interventions (telephone, home visits, letters) are recommended and may be particularly effective in resource-limited settings 1

When Medications ARE Indicated: Treating Underlying Disorders

For Comorbid Major Depression

• Selective serotonin reuptake inhibitors (SSRIs) such as escitalopram, sertraline, or fluoxetine may be prescribed when discrete and severe major depression coexists with self-harm 3
• Critical monitoring requirement: The highest risk for treatment-emergent suicidal thoughts occurs in the first 6 weeks of SSRI treatment, particularly in the first few weeks after starting or dose adjustments 2
• Avoid paroxetine as first-line therapy in young adults (ages 18-29), as it demonstrates the highest odds of nonfatal suicidal behavior among all SSRIs (number needed to harm = 370) 2
• Watch for akathisia (psychomotor restlessness), which can drive suicidal impulses and may require treatment with benzodiazepines or beta-blockers 2

For Borderline Personality Disorder

• No psychoactive medication consistently improves core symptoms of BPD, including self-harm behavior 3
• Meta-analyses provide little evidence supporting antidepressant use in BPD outside episodes of major depression 4
• For acute crisis management (extreme anxiety, psychotic episodes, or behavior endangering patient/others): low-potency antipsychotics like quetiapine or off-label sedative antihistamines like promethazine are preferred over benzodiazepines 3
• Mood stabilizers and antipsychotics have evidence for treating specific symptom domains (affective dysregulation, impulsive-behavioral dyscontrol, cognitive-perceptual symptoms) but not self-harm per se 4, 5

Long-Term Suicide Risk Reduction

• Lithium has significant evidence for reducing long-term suicide risk in mood disorders, though it has not been shown effective in acute settings 1
• Clozapine has FDA approval for "reducing the risk of recurrent suicidal behavior" but primarily in schizophrenia/schizoaffective disorder, not mood disorders which constitute the largest portion of suicide deaths 1

Essential Safety Interventions (Always Required)

Regardless of medication decisions, these non-pharmacological interventions are mandatory:

• Explicitly instruct the patient, family, and relevant others to remove all means of self-harm from the home, including pesticides, toxic substances, medications, and firearms 1, 2, 6
• Establish regular contact with healthcare provider for anyone with acts of self-harm in the past year 1, 6
• Implement safety planning interventions, which may be effective in reducing suicidal behavior post-discharge 1
• Facilitate social support from informal and/or formal community resources 1, 6

Critical Pitfalls to Avoid

• Never prescribe tricyclic antidepressants as first-line treatment in suicidal patients due to high lethality in overdose 2
• Use benzodiazepines and phenobarbital with extreme caution as they may increase disinhibition or impulsivity 2
• Do not assume "no-suicide contracts" provide meaningful protection—they do not replace vigilant monitoring 2
• Avoid prescribing large quantities of any medication that could be used as means of self-harm; evaluate appropriateness of medications like clonazepam in patients with suicidal thoughts 6
• Do not delay or substitute medication for comprehensive mental health assessment after any self-harm episode 2, 6

Monitoring Algorithm When Medications Are Used

1. First 6 weeks: Intensive monitoring for treatment-emergent suicidal ideation, particularly after starting or dose adjustments 2
2. Watch for behavioral activation/agitation early in treatment, which usually disappears quickly after dose adjustment or stopping 2
3. If suicidal thoughts emerge: Immediately lower dose or stop under close supervision 2
4. If thoughts don't improve within 1-2 weeks after stopping/adjusting: More likely related to underlying depression rather than medication 2
5. Be alert for discontinuation syndrome when stopping SSRIs, especially paroxetine, fluvoxamine, and sertraline (dizziness, nausea, anxiety, agitation within 24-48 hours) 2

Special Populations

Young People (Under 18)

• The absolute risk of suicidal thoughts with SSRIs is low: 1% with treatment vs 0.2% with placebo (number needed to harm = 143) 2
• Not treating depression poses much greater risk than potential SSRI risks—only 1.6% of youths who died by suicide were recently exposed to SSRIs 2
• Greater family involvement in treatment reduces non-adherence and improves outcomes 1

Older Adults

• SSRIs carry significant risk for upper gastrointestinal bleeding, increasing dramatically with age (4.1 per 1000 at ages 65-70 to 12.3 per 1000 in octogenarians) 2
• Citalopram carries dose-dependent QT prolongation risk; FDA limits doses to ≤40 mg/day in adults and ≤20 mg/day in adults over 60 years 2
• Do not dismiss self-harm thoughts in older adults, as this population may be at higher risk for completed suicide 6

Bottom Line

The evidence is clear and consistent: medications alone do not treat self-harm behavior. 1 Psychotherapy remains the treatment of choice, with medications reserved for treating specific comorbid psychiatric disorders. When medications are used, they must be combined with comprehensive safety planning, means restriction, regular monitoring, and psychosocial interventions. 1, 2, 6