Help-seeking duration and its impact on the course of non-suicidal self-injury and suicide attempts in outpatient adolescents

The study addresses whether the duration between the onset of suicidal thoughts and/or self-harming behaviors (NSSI, suicide attempts) and first contact with mental health services (help-seeking duration, HS-DU) influences subsequent self-harm outcomes after treatment in adolescents. Prior research shows high prevalence of NSSI and suicidality among youths and frequent delays or absence of help-seeking. Delayed help-seeking has been associated with worse outcomes in various psychiatric conditions, and progression from ideation to attempts is theorized in the ideation-to-action framework. The authors hypothesized that longer delays in seeking help after first suicidal thoughts and/or self-harm would be associated with higher frequencies of subsequent NSSI and suicide attempts. They also explored the reverse sequence (onset after first professional contact, negative HS-DU) to understand its relation to later self-harm. Understanding these relationships is important for optimizing intervention timing and improving outcomes in a high-risk adolescent population.

Background literature indicates: (1) Self-harm (NSSI and suicidal behavior) in youth is prevalent and predicts later suicide attempts and death by suicide. (2) Many adolescents with suicidal thoughts/self-harm do not seek help, or seek help after substantial delays; prior work reported average delays around 20 months after first NSSI/ideation and about 1 year after first suicide attempt. (3) The ideation-to-action framework posits that suicidal ideation and acquired capability for self-harm precede suicide attempts; epidemiological data show attempts typically follow NSSI and ideation by 1–2 years. (4) Prolonged duration of untreated illness (DUI) is linked to worse clinical trajectories in several disorders and to increased self-harm risk during the untreated period; first-episode psychosis literature shows negative effects of prolonged DUI on post-treatment outcomes. (5) Only one adult, population-based study reported that rapid psychiatric contact after a first suicide attempt reduced reattempt risk at 5 years, suggesting early help-seeking may be protective. However, definitions and measurement of help-seeking delay vary across studies; structured and dimensional assessments (e.g., SITBI-G) are recommended for comparability. This study fills a gap by prospectively testing HS-DU effects on self-harm outcomes in treated adolescent outpatients.

Design: Prospective cohort study with baseline and 1-year follow-up assessments among adolescents seeking outpatient treatment for self-harm at the AtR!Sk clinic (University Hospital Heidelberg). Treatment followed a standardized stepped-care model including short-term CBT for NSSI and/or dialectical behavior therapy for adolescents (DBT-A), with psychiatric management and crisis interventions as needed. Participants and setting: Adolescents at high risk for self-harm receiving care at AtR!Sk were consecutively recruited (June 2013–May 2021). Ethics approval: Medical Faculty Heidelberg (ID S-449/2013). Informed consent obtained from adolescents and guardians. Final analysis sample n = 285 (88% female), mean age 15.11 years (SD 1.44; range 11–17). Recruitment flow: 674 recruited; excluded for missing or inconsistent key dates (n = 121), missing outcome data at baseline or follow-up (n = 254), and age at first psychiatric contact <6 years (n = 14), yielding 285 with complete baseline and 1-year data. Measures: Sociodemographics; MINI-KID (German) for diagnoses; SITBI-G for ages at onset of first NSSI, suicidal thoughts, and suicide attempt; frequencies of NSSI (past 6 months) and suicide attempts (past 12 months) at baseline and 1-year follow-up; reasons for suicidal behavior at baseline (multiple-choice). Year of first contact with professional child/adolescent psychiatric or psychological service recorded. Baseline symptom severity: SCL-90-R Global Severity Index; depressive symptoms: Depression Inventory for Children and Adolescents (German). Help-seeking duration (HS-DU): Computed as age at first psychiatric contact minus age at first NSSI/ideation/attempt. Positive values indicate help-seeking delay (HS-DE: symptom onset before first contact). Negative values indicate onset after first contact (negative HS-DU). Age at first psychiatric contact derived from year of first contact minus year of birth. Outcomes: Frequency of NSSI (days in past 6 months) and suicide attempts (count categories in past 12 months: 0, 1, >1) at baseline and 1-year follow-up. Statistical analysis: Generalized mixed-effects models with random intercept per participant to account for within-subject non-independence across timepoints. For suicide attempts: mixed-effects ordinal logistic regression (0, 1, >1). For NSSI frequency: negative binomial regression due to overdispersion. Fixed effects entered stepwise: age, sex, time (baseline vs follow-up), indicator (HS-DE vs negative HS-DU), continuous HS-DE and negative HS-DU terms, and two-way interactions with time. To address potential confounding by age at onset, age at first suicidal thoughts and age at first NSSI were added to corresponding models. Additional analyses controlled for baseline general symptom severity (SCL-90-R GSI) and depressive symptoms (DIKJ). Alpha = 0.05. Software: Stata/SE 16.0.

- Help-seeking timing distributions: Mean delay from symptom onset to first professional contact (HS-DE) was 2.06 years (SD 1.99; range 0.01–10.01) for suicidal thoughts, 1.90 years (SD 1.83; 0.01–10.36) for first NSSI, and 1.42 years (SD 1.40; 0.01–5.04) for first suicide attempt. Negative HS-DU (onset after first contact) proportions: 32% for suicidal ideation, 29% for NSSI, and 57% for suicide attempts. - Descriptive change in outcomes: Mean suicide attempts (past 12 months) decreased from 1.14 (SD 3.90) at baseline to 0.52 (SD 1.41) at follow-up. Mean NSSI days (past 6 months) decreased from 37.62 (SD 43.70) to 23.95 (SD 47.95). - Primary associations: No significant associations between HS-DE or negative HS-DU (for first NSSI, suicidal thoughts, or suicide attempt) and future frequencies of NSSI or suicide attempts at 1-year follow-up. Time effect was significant, indicating reductions in both NSSI and suicide attempts from baseline to follow-up across groups. - Age effects: Earlier ages at onset of NSSI and suicidal thoughts were significantly associated with higher numbers of suicide attempts at baseline and follow-up. Younger baseline age (in those with NSSI history) predicted higher NSSI at follow-up, whereas older baseline age (in those with histories of suicidal thoughts and NSSI) predicted more suicide attempts at follow-up. - Symptom severity: Baseline general symptom severity and depressive symptoms were significantly associated with higher frequencies of NSSI and suicide attempts at follow-up in some models, yet reductions from baseline to follow-up remained significant and HS-DU effects remained non-significant after adjustment. - Reasons for suicide attempts: Predominantly psychiatric conditions (66% HS-DE; 82% negative HS-DU) and family conflicts (55% HS-DE; 42% negative HS-DU), followed by school stress (27% HS-DE) and conflicts with friends (26% negative HS-DU).

Findings directly address the hypothesis that longer delays in seeking professional help after the onset of NSSI, suicidal ideation, or suicide attempts would predict worse self-harm outcomes following treatment. Contrary to expectations and to literature in other disorders, HS-DU (both delays and negative durations) was not associated with the frequency of NSSI or suicide attempts one year later among adolescents receiving structured outpatient interventions. The robust time effect indicates that specialized treatments (CBT for NSSI, DBT-A, and psychiatric management) were associated with significant reductions in self-harm, suggesting that effective intervention can mitigate risks even when help is sought late. Age-related patterns underscore developmental risk: earlier onset of ideation/NSSI predicts greater propensity for later suicide attempts, and baseline age differentially relates to subsequent NSSI versus attempts. Comparisons with first-episode psychosis literature highlight possible disorder-specific differences in the impact of untreated duration on post-treatment trajectories. Methodological differences from adult population studies (e.g., South Korean cohort) likely explain discrepant findings regarding early contact after attempts. Overall, the results support the clinical message that timely treatment is beneficial across the spectrum of help-seeking histories, while emphasizing vigilance for youths with early onset of self-harm-related phenomena.

This first longitudinal study of help-seeking duration and subsequent self-harm among treated adolescent outpatients found no detrimental effect of delayed help-seeking on 1-year outcomes; instead, significant reductions in NSSI and suicide attempts occurred across the sample following structured psychotherapy. Adolescents with earlier onset of suicidal thoughts and NSSI are at elevated risk of progression to suicide attempts, indicating a critical target for early identification and intervention. Future research should: (1) include more male adolescents to assess generalizability and potential sex differences; (2) examine longer-term outcomes across the transition to adulthood; (3) incorporate control groups and diverse treatment settings (including inpatient care) to delineate treatment versus naturalistic effects; and (4) use standardized, dimensional assessments of HS-DU to improve cross-study comparability.

- Sample composition: Predominantly female (88%), limiting generalizability to males. - No control group: Limits causal inference about treatment effects versus natural course. - Retrospective timing: Ages at onset and first psychiatric contact were retrospectively reported, introducing potential recall bias, albeit via structured clinical interviews. - Limited help-seeking detail: Only the year of first psychiatric contact was collected; details on contact intensity, reasons for help-seeking, or pre-existing diagnoses were not captured. - Attrition: High loss to follow-up (n=219) reduced analyzable sample from 674 to 285; outcomes for those lost may differ, potentially biasing results. - Setting and severity: Outpatient treatment focus may exclude adolescents requiring inpatient care or those who died by suicide before study participation, limiting generalizability to more severe cases.