Self-harm, encompassing NSSI and suicidal behavior, is a significant risk factor for suicide in adolescents. A substantial proportion of adolescents with self-harming behaviors do not seek professional help, or do so with considerable delay. Previous research from the authors' group indicated an average delay of 20 months for first NSSI and suicidal thoughts, and one year after a first suicide attempt before seeking help. This delay aligns with broader findings demonstrating significant delays in help-seeking for various mental disorders. The Ideation-to-Action Framework posits that suicidal thoughts and self-harm capabilities precede suicidal behavior, with studies suggesting suicide attempts occur years after initial NSSI and suicidal thoughts. Delayed treatment is concerning due to the increased risk of recurrence and escalation of self-harming behaviors. While effective treatment programs like Dialectical Behavior Therapy and the Cutting Down Programme exist, the long-term impact of delayed help-seeking beyond the point of professional intervention remains poorly understood. Existing literature primarily focuses on the negative effects of delayed treatment prior to professional help, but the consequences after help-seeking are less clear. This study aimed to examine the influence of the duration between the onset of suicidal thoughts/self-harm and first professional contact, and vice versa, on the frequency of future self-harm in adolescents receiving outpatient treatment. The hypothesis was that prolonged delay would increase the risk of subsequent NSSI and suicide attempts.

The introduction thoroughly reviews the existing literature on self-harm in adolescents, highlighting the prevalence, risk factors (including delayed help-seeking), and the effectiveness of established treatment programs such as Dialectical Behavior Therapy and the Cutting Down Programme. It emphasizes the gap in knowledge regarding the long-term effects of delayed help-seeking *after* the initiation of professional care. Studies on first-episode psychosis show negative impacts of delayed treatment, but this relationship hasn't been adequately explored for self-harm in adolescents. One South Korean study on adults found that early presentation after a suicide attempt was associated with a reduced risk of reattempt, but this finding needs further investigation in adolescent populations with diverse treatment approaches.

This prospective cohort study utilized data from the outpatient clinic for adolescent risk-taking and self-harming behavior (AtR!Sk) at the University Hospital Heidelberg. 285 adolescent outpatients (88% female, mean age 15.11 years) were included. Data were collected between June 2013 and May 2021. The study employed the German version of the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) to assess psychiatric diagnoses, and the Self-Injurious Thoughts and Behaviors Interview (SITBI-G) to assess the age of onset of NSSI, suicidal thoughts, and suicide attempts, along with the frequency of these behaviors. HS-DU was calculated by subtracting the age of symptom onset from the age of first professional contact. Positive scores indicated a delay in seeking help, while negative scores indicated symptom onset after initial contact. The Symptom-Checklist-90-Revised and the Depression Inventory for Children and Adolescents measured general symptom severity and depressive symptoms. Generalized linear mixed models were used to analyze the associations between HS-DU and the frequency of NSSI and suicide attempts at baseline and 1-year follow-up, controlling for age and gender. Mixed-effects ordinal logistic regression and negative binomial regression models were used depending on the outcome variable.

A significant decrease in the frequency of self-harm (both NSSI and suicide attempts) was observed from baseline to the 1-year follow-up. Crucially, no significant association was found between HS-DU (both positive and negative) and the frequency of future self-harm. Age at onset of NSSI and suicidal thoughts was negatively associated with the number of suicide attempts at both time points; younger age at onset was associated with a higher frequency of future suicide attempts. Younger age at baseline was also associated with higher NSSI frequency at follow-up. The study also found a significant reduction in self-harm from baseline to follow-up across all groups, regardless of HS-DU. General symptom severity and depressive symptoms significantly affected the frequency of NSSI and suicide attempts at follow-up.

The study's primary finding—the lack of association between HS-DU and future self-harm—challenges the expectation that delayed help-seeking would negatively impact treatment outcomes. This suggests that specialized treatment programs are effective even when adolescents seek help late. The findings contrast with research on first-episode psychosis, where delayed treatment has a more pronounced negative effect. This highlights the potential for greater reversibility of self-harm in adolescents compared to some other mental disorders. The age-related findings emphasize the vulnerability of adolescents with early-onset self-harm to symptom progression. The significant reduction in self-harm observed across all groups underscores the benefit of the structured treatment program offered at AtR!Sk.

This study provides valuable insights into the impact of help-seeking duration on self-harm in adolescents. Despite delayed help-seeking, significant reductions in self-harm were observed after treatment. Adolescents with early-onset self-harm warrant particular attention due to their higher risk of symptom progression. Further research, particularly focusing on male adolescents and exploring the interaction between HS-DU, treatment modalities, and other clinical factors, is needed to refine our understanding of this complex issue.

The study's limitations include the predominantly female sample, limiting generalizability to male adolescents. The absence of a control group makes it challenging to isolate the treatment effect. Retrospective data collection may have introduced recall bias. The study only considered the time of first professional contact, neglecting potentially relevant details such as the nature of initial contact. A significant number of participants were lost to follow-up, potentially influencing the findings. Finally, the sample focuses on outpatients, excluding those with more severe self-harm treated in inpatient settings or those who died by suicide.