A Youth Culturally adapted Manual Assisted Psychological therapy (Y-CMAP) for adolescent Pakistani patients with a recent history of self-harm.

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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. The 1.8% total global burden of disease attributed to suicide in 1998 is expected to increase to 2.4% by 2020. The WHO Mental Health Action Plan 2013-2020 and all the member states have committed to work towards the global target of a 10% reduction in the suicide rate by 2020. WHO's Mental Health Gap Action Programme includes suicide as one of the priority conditions and the recent WHO report "Preventing suicide: a global imperative" calls for suicide prevention to be a high priority on the global public health agenda. More than 800,000 people across the world die due to suicide each year and for each suicide there are more than 20 people attempting suicide. Self-harm is one of the strongest predictors of death by suicide in adolescence, increasing the risk approximately 10-fold. Each suicide takes the life of the individual and has a tremendous effect on friends, family and the wider community. Up to 75% of all suicides occur in in low- and middle-income countries (LMIC) where resources and services are limited for treatment and support. There is a clear gap in the robust evaluation of culturally appropriate suicide prevention strategies in LMIC. 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 offering appropriate treatment as a key component of all suicide prevention strategies.There are more than 100,000 acts of self-harm in Pakistan annually. The aim of Y-CMAP is to evaluate the clinical and cost-effectiveness of this culturally adapted psychological therapy in adolescent patients with a history of self-harm. Our study in Karachi determined the effectiveness of a 6-8 session CBT-based intervention (C MAP) in adults who had recently self-harmed. The assessments were carried out at baseline, 3 & 6 months. There was a significant reduction from baseline in suicidal ideation and hopelessness in the intervention group compared to the Treatment as Usual (TAU) group at each follow up assessment. The findings from C MAP highlight the applicability of such an intervention to health services in Pakistan for patients who present after a self-harm episode. The proposed research will be conducted in Karachi, Lahore, Rawalpindi, Multan and Hyderabad. Participants will be randomized either to the Intervention (Y-CMAP) or TAU. The existing age appropriate culturally adapted intervention (Y-CMAP) for young people includes an evaluation of the self-harm episode, crisis skills, problem solving and basic cognitive techniques to manage emotions, negative thinking and relapse prevention strategies. The intervention will be delivered in eight sessions over 12 weeks. Assessments will be conducted at baseline and at 3 months (end of intervention), 6 months and 12 months after randomization. The outcome measures will include questionnaires to measure the repetition of self-harm, severity of suicidal ideation; depression; hopelessness; and quality of life. In addition, qualitative interviews and focus groups will provide rich information regarding the experiences of participants, therapists and key stakeholders. This will inform implementation as well as the development of more effective and sensitive services for self-harm management. TAU will be standard routine care delivered by local medical, psychiatric and primary care services according to clinical judgment. A record will be kept of any treatment received by each participant. This trial will inform future research and national clinical practice guidelines. We have established contacts with the ministry of health and will enter discussions to present the results to them and attempt to influence policy change.