A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial

Nusrat Husain; Tayyeba Kiran; Imran Bashir Chaudhry; Christopher Williams; Richard Emsley; Usman Arshad; Moin Ahmed Ansari; Paul Bassett; Penny Bee; Moti Ram Bhatia; Carolyn Chew-Graham; Muhammad Omair Husain; Muhammad Irfan; Ayesha Khaliq; Fareed A Minhas; Farooq Naeem; Haider Naqvi; Asad Tamizuddin Nizami; Amna Noureen; Maria Panagioti; Ghulam Rasool; Sofiya Saeed; Sumira Qambar Bukhari; Sehrish Tofique; Zainab F Zadeh; Shehla Naeem Zafar; Nasim Chaudhry

doi:10.1186/s12916-023-02983-8

A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial

Nusrat Husain, Tayyeba Kiran, Imran Bashir Chaudhry, Christopher Williams, Richard Emsley, Usman Arshad, Moin Ahmed Ansari, Paul Bassett, Penny Bee, Moti Ram Bhatia, Carolyn Chew-Graham, Muhammad Omair Husain, Muhammad Irfan, Ayesha Khaliq, Fareed A Minhas, Farooq Naeem, Haider Naqvi, Asad Tamizuddin Nizami, Amna Noureen, Maria PanagiotiGhulam Rasool, Sofiya Saeed, Sumira Qambar Bukhari, Sehrish Tofique, Zainab F Zadeh, Shehla Naeem Zafar, Nasim Chaudhry

Research output: Contribution to journal › Article › peer-review

1 Citation (Scopus)

Abstract

BACKGROUND: Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm.

METHODS: This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016).

RESULTS: We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (- 3.6 (- 4.9, - 2.4)), depression (- 7.1 (- 8.7, - 5.4)), hopelessness (- 2.6 (- 3.4, - 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention.

CONCLUSIONS: Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

Original language	English
Article number	282
Pages (from-to)	282
Journal	BMC Medicine
Volume	21
Issue number	1
DOIs	https://doi.org/10.1186/s12916-023-02983-8
Publication status	Published - 31 Jul 2023

Keywords

Humans
Adult
Quality of Life
Self-Injurious Behavior/prevention & control
Suicide
Cognitive Behavioral Therapy
Suicidal Ideation

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1186/s12916-023-02983-8

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Husain, N., Kiran, T., Chaudhry, I. B., Williams, C., Emsley, R., Arshad, U., Ansari, M. A., Bassett, P., Bee, P., Bhatia, M. R., Chew-Graham, C., Husain, M. O., Irfan, M., Khaliq, A., Minhas, F. A., Naeem, F., Naqvi, H., Nizami, A. T., Noureen, A., ... Chaudhry, N. (2023). A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial. BMC Medicine, 21(1), 282. Article 282. https://doi.org/10.1186/s12916-023-02983-8

@article{059b5f66509a4da685531e4372afa38e,

title = "A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial",

abstract = "BACKGROUND: Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm.METHODS: This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016).RESULTS: We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (- 3.6 (- 4.9, - 2.4)), depression (- 7.1 (- 8.7, - 5.4)), hopelessness (- 2.6 (- 3.4, - 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention.CONCLUSIONS: Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.",

keywords = "Humans, Adult, Quality of Life, Self-Injurious Behavior/prevention & control, Suicide, Cognitive Behavioral Therapy, Suicidal Ideation",

author = "Nusrat Husain and Tayyeba Kiran and Chaudhry, {Imran Bashir} and Christopher Williams and Richard Emsley and Usman Arshad and Ansari, {Moin Ahmed} and Paul Bassett and Penny Bee and Bhatia, {Moti Ram} and Carolyn Chew-Graham and Husain, {Muhammad Omair} and Muhammad Irfan and Ayesha Khaliq and Minhas, {Fareed A} and Farooq Naeem and Haider Naqvi and Nizami, {Asad Tamizuddin} and Amna Noureen and Maria Panagioti and Ghulam Rasool and Sofiya Saeed and Bukhari, {Sumira Qambar} and Sehrish Tofique and Zadeh, {Zainab F} and Zafar, {Shehla Naeem} and Nasim Chaudhry",

note = "Funding Information: Funding support for this study was provided by the MRC/Wellcome Trust/DFID (MR/N006062/1). The funders had no role in the study design, collection, analysis or interpretation of the data, writing of the manuscript, or the decision to submit the manuscript for publication. Funding Information: NC is the CEO of the Pakistan Institute of Living and Learning. She is Associate Director of the Global Mental Health and Cultural Psychiatry Research Group, Head of Psychological Medicine at the Remedial Centre Hospital, Consultant Psychiatrist at South City Hospital, Consultant for Manchester Global Foundation and Professor of Psychiatry, Dow University of Health Sciences. NC has received travel grants from Lundbeck and Pfizer pharmaceutical companies to attend one national and one international academic meeting and conference in the last three years. She is a chief investigator and co-investigator for a number of research projects funded by various grant bodies such as the Medical Research Council, Welcome Trust, NIH-R, and Global Challenges Research Fund. Funding Information: We would like to thank our Participant and Public Involvement and Engagement (PPIE) group, all the participants who participated in the trial, their families, and our community engagement officers. We want to thank our Trial Steering Committee (Chair Prof David Kingdon, Members: Trial Statistician – RE, Service user representative – SK, Funder observer—Mary Desilva) and Data Management and Ethics Committee (DMEC) (independent statisticians – Kimberley Goldsmith, clinicians – Prof Mowadat H Rana, Dr Rashid Qadir). We are thankful to authors Ulrike Schmidt and Kate Davidson for allowing us to translate, culturally adapt and use the self-help manual “Life after Self-Harm a Guide to the Future” as well as to the Manual Translation and Cultural Adaptation group of the Pakistan Institute of Living and Learning (PILL). We want to thank all the nurses, GPs, clinicians, heads of emergency departments, psychiatry and medical units of participating hospitals for their support in the screening and recruitment of participants for the trial. We would also like to thank all researchers and therapists involved throughout the trial (Ameer B Khoso, Shafaq Ijaz, Maham Rasheed, Majid Sanjrani, Ghulam Qadir, Sehrish Irshad, Zaib un Nisa, Tahira Khalid, Farooq Ahemd, Samia Shahid, Humera Khalid, Rab Dino, Rabia Sattar, Maheshwari Bebo, Sanum Hakro, Akhtar Zaman, Nawaz Khan, Muqaddas Jabeen, Shoaib Khalid, Raja M. Talha, Muhammad Asif, Maria Usman, Sana Farooque, Raheel Ahmed, Farhat ul Ain, Nayab Zafar, Mahum Izhar, Asif Ali (late), Ali Raza, Hadiyya tur Rehman, Muqaddas Asif, Farhat ul Ain, Qurat ul ain, Mehak Bano, Junaid Ikhlaq, Zainab Bibi, Umair Ahsan, Hira Jaffer, Sanaullah Kakar, Faster Gill, Summaiya Shahid, Uzma Attique Khan, Farah Naz, Shahida Kausar, Raees Jokhio, Bano, Nimra, Mehreen Khan, Najma Aziz). Special thanks to Sami Ansari – data manager. Publisher Copyright: {\textcopyright} 2023, The Author(s).",

year = "2023",

month = jul,

day = "31",

doi = "10.1186/s12916-023-02983-8",

language = "English",

volume = "21",

pages = "282",

journal = "BMC Medicine",

issn = "1741-7015",

publisher = "BIOMED CENTRAL LTD",

number = "1",

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Husain, N, Kiran, T, Chaudhry, IB, Williams, C, Emsley, R, Arshad, U, Ansari, MA, Bassett, P, Bee, P, Bhatia, MR, Chew-Graham, C, Husain, MO, Irfan, M, Khaliq, A, Minhas, FA, Naeem, F, Naqvi, H, Nizami, AT, Noureen, A, Panagioti, M, Rasool, G, Saeed, S, Bukhari, SQ, Tofique, S, Zadeh, ZF, Zafar, SN & Chaudhry, N 2023, 'A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial', BMC Medicine, vol. 21, no. 1, 282, pp. 282. https://doi.org/10.1186/s12916-023-02983-8

TY - JOUR

T1 - A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm

T2 - a multi-centre randomised controlled trial

AU - Husain, Nusrat

AU - Kiran, Tayyeba

AU - Chaudhry, Imran Bashir

AU - Williams, Christopher

AU - Emsley, Richard

AU - Arshad, Usman

AU - Ansari, Moin Ahmed

AU - Bassett, Paul

AU - Bee, Penny

AU - Bhatia, Moti Ram

AU - Chew-Graham, Carolyn

AU - Husain, Muhammad Omair

AU - Irfan, Muhammad

AU - Khaliq, Ayesha

AU - Minhas, Fareed A

AU - Naeem, Farooq

AU - Naqvi, Haider

AU - Nizami, Asad Tamizuddin

AU - Noureen, Amna

AU - Panagioti, Maria

AU - Rasool, Ghulam

AU - Saeed, Sofiya

AU - Bukhari, Sumira Qambar

AU - Tofique, Sehrish

AU - Zadeh, Zainab F

AU - Zafar, Shehla Naeem

AU - Chaudhry, Nasim

N1 - Funding Information: Funding support for this study was provided by the MRC/Wellcome Trust/DFID (MR/N006062/1). The funders had no role in the study design, collection, analysis or interpretation of the data, writing of the manuscript, or the decision to submit the manuscript for publication. Funding Information: NC is the CEO of the Pakistan Institute of Living and Learning. She is Associate Director of the Global Mental Health and Cultural Psychiatry Research Group, Head of Psychological Medicine at the Remedial Centre Hospital, Consultant Psychiatrist at South City Hospital, Consultant for Manchester Global Foundation and Professor of Psychiatry, Dow University of Health Sciences. NC has received travel grants from Lundbeck and Pfizer pharmaceutical companies to attend one national and one international academic meeting and conference in the last three years. She is a chief investigator and co-investigator for a number of research projects funded by various grant bodies such as the Medical Research Council, Welcome Trust, NIH-R, and Global Challenges Research Fund. Funding Information: We would like to thank our Participant and Public Involvement and Engagement (PPIE) group, all the participants who participated in the trial, their families, and our community engagement officers. We want to thank our Trial Steering Committee (Chair Prof David Kingdon, Members: Trial Statistician – RE, Service user representative – SK, Funder observer—Mary Desilva) and Data Management and Ethics Committee (DMEC) (independent statisticians – Kimberley Goldsmith, clinicians – Prof Mowadat H Rana, Dr Rashid Qadir). We are thankful to authors Ulrike Schmidt and Kate Davidson for allowing us to translate, culturally adapt and use the self-help manual “Life after Self-Harm a Guide to the Future” as well as to the Manual Translation and Cultural Adaptation group of the Pakistan Institute of Living and Learning (PILL). We want to thank all the nurses, GPs, clinicians, heads of emergency departments, psychiatry and medical units of participating hospitals for their support in the screening and recruitment of participants for the trial. We would also like to thank all researchers and therapists involved throughout the trial (Ameer B Khoso, Shafaq Ijaz, Maham Rasheed, Majid Sanjrani, Ghulam Qadir, Sehrish Irshad, Zaib un Nisa, Tahira Khalid, Farooq Ahemd, Samia Shahid, Humera Khalid, Rab Dino, Rabia Sattar, Maheshwari Bebo, Sanum Hakro, Akhtar Zaman, Nawaz Khan, Muqaddas Jabeen, Shoaib Khalid, Raja M. Talha, Muhammad Asif, Maria Usman, Sana Farooque, Raheel Ahmed, Farhat ul Ain, Nayab Zafar, Mahum Izhar, Asif Ali (late), Ali Raza, Hadiyya tur Rehman, Muqaddas Asif, Farhat ul Ain, Qurat ul ain, Mehak Bano, Junaid Ikhlaq, Zainab Bibi, Umair Ahsan, Hira Jaffer, Sanaullah Kakar, Faster Gill, Summaiya Shahid, Uzma Attique Khan, Farah Naz, Shahida Kausar, Raees Jokhio, Bano, Nimra, Mehreen Khan, Najma Aziz). Special thanks to Sami Ansari – data manager. Publisher Copyright: © 2023, The Author(s).

PY - 2023/7/31

Y1 - 2023/7/31

N2 - BACKGROUND: Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm.METHODS: This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016).RESULTS: We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (- 3.6 (- 4.9, - 2.4)), depression (- 7.1 (- 8.7, - 5.4)), hopelessness (- 2.6 (- 3.4, - 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention.CONCLUSIONS: Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

AB - BACKGROUND: Self-harm is an important predictor of a suicide death. Culturally appropriate strategies for the prevention of self-harm and suicide are needed but the evidence is very limited from low- and middle-income countries (LMICs). This study aims to investigate the effectiveness of a culturally adapted manual-assisted problem-solving intervention (CMAP) for patients presenting after self-harm.METHODS: This was a rater-blind, multicenter randomised controlled trial. The study sites were all participating emergency departments, medical wards of general hospitals and primary care centres in Karachi, Lahore, Rawalpindi, Peshawar, and Quetta, Pakistan. Patients presenting after a self-harm episode (n = 901) to participating recruitment sites were assessed and randomised (1:1) to one of the two arms; CMAP with enhanced treatment as usual (E-TAU) or E-TAU. The intervention (CMAP) is a manual-assisted, cognitive behaviour therapy (CBT)-informed problem-focused therapy, comprising six one-to-one sessions delivered over three months. Repetition of self-harm at 12-month post-randomisation was the primary outcome and secondary outcomes included suicidal ideation, hopelessness, depression, health-related quality of life (QoL), coping resources, and level of satisfaction with service received, assessed at baseline, 3-, 6-, 9-, and 12-month post-randomisation. The trial is registered on ClinicalTrials.gov. NCT02742922 (April 2016).RESULTS: We screened 3786 patients for eligibility and 901 eligible, consented patients were randomly assigned to the CMAP plus E-TAU arm (n = 440) and E-TAU arm (N = 461). The number of self-harm repetitions for CMAP plus E-TAU was lower (n = 17) compared to the E-TAU arm (n = 23) at 12-month post-randomisation, but the difference was not statistically significant (p = 0.407). There was a statistically and clinically significant reduction in other outcomes including suicidal ideation (- 3.6 (- 4.9, - 2.4)), depression (- 7.1 (- 8.7, - 5.4)), hopelessness (- 2.6 (- 3.4, - 1.8), and improvement in health-related QoL and coping resources after completion of the intervention in the CMAP plus E-TAU arm compared to the E-TAU arm. The effect was sustained at 12-month follow-up for all the outcomes except for suicidal ideation and hopelessness. On suicidal ideation and hopelessness, participants in the intervention arm scored lower compared to the E-TAU arm but the difference was not statistically significant, though the participants in both arms were in low-risk category at 12-month follow-up. The improvement in both arms is explained by the established role of enhanced care in suicide prevention.CONCLUSIONS: Suicidal ideation is considered an important target for the prevention of suicide, therefore, CMAP intervention should be considered for inclusion in the self-harm and suicide prevention guidelines. Given the improvement in the E-TAU arm, the potential use of brief interventions such as regular contact requires further exploration.

KW - Humans

KW - Adult

KW - Quality of Life

KW - Self-Injurious Behavior/prevention & control

KW - Suicide

KW - Cognitive Behavioral Therapy

KW - Suicidal Ideation

UR - http://www.scopus.com/inward/record.url?scp=85166040417&partnerID=8YFLogxK

U2 - 10.1186/s12916-023-02983-8

DO - 10.1186/s12916-023-02983-8

M3 - Article

C2 - 37525207

SN - 1741-7015

VL - 21

SP - 282

JO - BMC Medicine

JF - BMC Medicine

IS - 1

M1 - 282

ER -

A culturally adapted manual-assisted problem-solving intervention (CMAP) for adults with a history of self-harm: a multi-centre randomised controlled trial

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UN SDGs

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