What is the appropriate next step for a 16‑year‑old male with major depressive disorder, generalized anxiety disorder, and obsessive‑compulsive disorder who is taking sertraline 150 mg daily and Wellbutrin XL (bupropion) 300 mg daily, continues to be depressed, and has recently self‑harmed by cutting?

Immediate Mental Health Evaluation and Safety Planning

This 16-year-old with active self-harm by cutting requires immediate mental health professional evaluation to determine appropriate level of care, with strong consideration for psychiatric hospitalization given the recent self-harm in the context of treatment-refractory depression. 1, 2

Risk Assessment and Disposition Decision

The patient meets multiple high-risk criteria that warrant urgent psychiatric evaluation:

• Recent self-harm behavior (cutting) despite ongoing pharmacotherapy indicates treatment failure and elevated risk 1, 3
• Treatment-refractory depression on adequate doses of sertraline 150mg and bupropion XL 300mg suggests need for intensive intervention 1, 4
• Multiple psychiatric comorbidities (MDD, GAD, OCD) increase complexity and risk 1

Psychiatric hospitalization should be strongly considered if any of the following are present: persistent wish to die, inability to form therapeutic alliance, low impulse control, or inadequate home supervision. 1, 2 Outpatient management is only appropriate if there is a responsive and supportive family, no current suicidal intent or plan, and someone available to monitor 24/7 with immediate same-day mental health appointment arranged. 1, 2

Mandatory Safety Interventions (Non-Negotiable)

Before any discharge or while awaiting psychiatric evaluation:

• Remove ALL firearms from the home immediately - this is the single most critical intervention 1, 2
• Lock up all medications (prescription and over-the-counter) 1, 2
• Secure knives and other sharp objects given the cutting behavior 2, 5
• Restrict access to alcohol and substances 2, 5

Evidence-Based Psychotherapy: First-Line Treatment

Dialectical Behavior Therapy for Adolescents (DBT-A) is the first-line psychotherapy for adolescent self-harm, demonstrating the strongest evidence with 30% repeat self-harm versus 43% in control groups (OR 0.46,95% CI 0.26-0.82). 1, 4

DBT-A requires:

• Intensive 3-6 month program with weekly group, family, and individual sessions plus telephone coaching 4
• Focus on emotion regulation, interpersonal effectiveness, and distress tolerance skills 4
• This is the most effective intervention but may not be accessible due to resource limitations 1, 4

If DBT-A is unavailable, adapted Cognitive-Behavioral Therapy (CBT) should be provided, which reduces post-treatment suicide attempts by approximately 50% compared with treatment-as-usual. 4 Key adaptations include:

• Language tailored to adolescent developmental level 1, 4
• Specific inclusion of self-harm and suicidal content within depression treatment (critical - depression treatment alone may not address persistent self-harm ideation) 1, 4
• Typical duration up to 15 weeks 4

Pharmacotherapy Management

Continue current sertraline 150mg and bupropion XL 300mg to treat the underlying psychiatric disorders (MDD, GAD, OCD). 1, 4, 6, 7, 8 The combination of sertraline (SSRI) and bupropion (NDRI) has demonstrated efficacy in treatment-refractory depression through synergistic serotonergic, dopaminergic, and noradrenergic mechanisms. 9

Critical caveat: Pharmacotherapy should NOT be used as the sole strategy to prevent self-harm - there is no evidence supporting medication alone for self-harm prevention in adolescents. 1, 4 Medications address underlying psychiatric conditions but must be combined with evidence-based psychotherapy.

Consider medication optimization only after comprehensive psychiatric evaluation, as the current doses are within therapeutic range for all three conditions. 6, 7, 8

Family Involvement (Essential Component)

Involve the family wherever possible - this improves treatment adherence and outcomes. 1, 4 Specific strategies include:

• Carefully tailor involvement to the adolescent's preferences and family context 1, 4
• Address family factors that may perpetuate symptoms 1
• Engage families to reduce non-adherence, a common barrier to successful outcomes 4

Therapeutic Relationship and Assessment

A comprehensive therapeutic assessment must be performed immediately by a qualified mental health professional to:

• Identify specific factors driving the self-harm behavior 1, 4
• Develop a personalized risk-management plan 1, 4
• Establish an empathic, person-centered therapeutic relationship (negative clinical experiences can perpetuate self-harm cycles) 1, 4

The assessment should include:

• Formulation of contributing factors including internet/social media use, eating disorder symptoms, and family dynamics 1
• Safety planning with concrete coping strategies and identified supports rather than relying on "no-suicide contracts" (which are ineffective) 1, 2, 5

Follow-Up Requirements

Schedule follow-up within days (not weeks) after the initial assessment - the highest risk of re-attempt occurs in the months following presentation. 4, 2, 5

• Maintain contact even after psychiatric referral, as collaborative care between primary care and mental health professionals results in greater reduction of depressive symptoms 1, 5
• Monitor adherence to both psychotherapy and pharmacotherapy 4

Common Pitfalls to Avoid

• Do not discharge without psychiatric evaluation if any moderate-to-high risk factors are present 1
• Do not rely on "no-suicide contracts" - these have not been proven effective 1, 2, 5
• Do not treat depression alone without addressing self-harm content - self-harm ideation may persist even when depression improves 1, 4
• Do not add or change medications without comprehensive psychiatric evaluation - the current regimen is appropriate for the underlying conditions 1, 4