C-MAP (Culturally adapted Manual Assisted Psychological therapy) is a brief psychological intervention tailored for individuals with a history of self-harm, particularly in low- and middle-income countries like Pakistan.
The primary aim of C-MAP is to evaluate its clinical and cost-effectiveness in reducing repeated self-harm incidents and improving overall mental health outcomes.
Background
Suicide is a serious global public health issue ranked amongst the leading causes of death in many countries. The worldwide rates of suicide have increased by 60% in the last 45 years, and the 1.8% total global burden of disease attributed to suicide in 1998 is expected to increase to 2.4% by 2020.
Up to 75% of all suicides occur in in low- and middle-income countries where resources and services are limited for treatment and support for people who need. There is a clear gap in the robust evaluation of culturally appropriate suicide prevention strategies in low- and middle-income countries.
Individuals who have a history of self-harm are at much higher risk of dying by suicide than individuals who do not have such a history. The WHO recommends that offering them appropriate treatment should be a key component of all suicide prevention strategies.
Aims and Objectives
There are more than 100,000 acts of self-harm carried out in Pakistan annually. The aim of the proposed trial was to evaluate the clinical and cost-effectiveness of a culturally adapted psychological therapy (C-MAP) in patients with a history of self-harm.
This trial provided a detailed clinical and cost-effectiveness analyses for the management of self-harm which has been able to inform future research and national clinical practice guidelines.
We have established contacts with the ministry of health and entered discussions to present the results to them and attempt to influence policy change.
Methods
Design: A multicentre Randomised Control Trial to compare Treatment as Usual (TAU) plus the Culturally adapted Manual
Assisted Psychological therapy (C-MAP) with TAU in patients with a recent history of self-harm.
There was a built in 12 months internal pilot phase with clear stop/go criteria to prove viability to proceed to a full trial across all the study sites.
Participants were recruited from general practices, emergency departments and medical wards of participating hospitals.
Health Technologies that were assessed: A culturally adapted brief psychological intervention, based on the principles of Cognitive Behavioural Therapy (CBT). The intervention had 6 sessions, approximately 50 minutes each, and its feasibility has previously been established.
Sample Size: This trial used repetition of self-harm as its primary outcome measure because it is a strong predictor of completed suicide.
Randomised patients were required for a cluster adjusted test of proportions Measurement: The statistical analysis of the primary outcome measured repetition of self-harm episode and binary secondary outcome measures were based on a cluster adjusted test of proportions.
These were used to establish approaches to understand what factors block and facilitate successful delivery of the programme.
Benefits of the Research
The outcome of this trial had implications for the health services research, in terms of not only helping to improve the organisation to care for patients presenting with self-harm but also to improve the quality of health services research including health economics research.
One of the outputs of this study is a portfolio of user-defined, evidence-based, manual assisted interventions; a resource pack and training programme on ‘how to do it’ for use across local health services. These materials can be used for future research projects.
At the end of the research, we have answered how clinically effective, cost effective and acceptable the programme is, and summarised our findings in a delivery manual that can be freely used by other centres who might wish to deliver the same package in their centres.
The cost-effectiveness issue is important, as previous research in this field have failed to answer the important question of whether similar approaches are value for money.