Randomized Controlled Trial

. 2025 Sep 12:390:e083272.

doi: 10.1136/bmj-2024-083272.

Effectiveness of YCMAP (youth culturally adapted manual assisted problem solving) intervention in adolescents after self-harm in Pakistan: multicentre, randomised controlled trial

Nusrat Husain^{1

2}, Sehrish Tofique³, Tayyeba Kiran⁴, Matthias Pierce¹, Imran B Chaudhry^{1

5}, M Omair Husain^{6

7}, Rakhshi Memon^{8

9}, Ahmed Waqas¹⁰, Nadeem Gire¹, Sarah Edwards⁸, Paul Bassitt¹¹, Suleman Shakoor¹², Zainab F Zaddeh¹³, Usman Arshad¹⁴, Erminia Colucci¹⁵, Faraz Mughal^{16

17

18}, Samia Shahid⁴, Maria Panagioti¹⁹, Asad T Nizami²⁰, Farhat Jafri²¹, Farooq Naeem²², Richard Emsley²³, Moin A Ansari²⁴, Sarwat Sultan²⁵, Shilpa Aggarwal^{26

27}, Christopher Williams^{28

29}, Nasim Chaudhry³⁰

Affiliations

¹ Division of Psychology and Mental Health, The University of Manchester School of Health Sciences, Manchester, UK.
² Global Centre for Research on Mental Health Inequalities, Mersey Care NHS Foundation Trust, Prescot, UK.
³ Division of Neuro-Cognitive Disorder, Older Adults Mental Health, Pakistan Institute of Living and Learning, Karachi, Pakistan.
⁴ Division of Mood Disorder, Pakistan Institute of Living and Learning, Karachi, Pakistan.
⁵ Dr Ziauddin Hospital, Karachi, Pakistan.
⁶ Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
⁷ Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁸ Science and Technology Studies, University College London, London, UK.
⁹ Manchester Global Foundation, Manchester, UK.
¹⁰ Faculty of Health and Life Sciences, University of Liverpool, Liverpool UK.
¹¹ Statsconsultancy, Amersham, UK.
¹² Division of Biostatistics, Pakistan Institute of Living and Learning, Karachi, Pakistan.
¹³ Division of Child and Adolescents, Pakistan Institute of Living and Learning, Karachi, Pakistan.
¹⁴ Department of Evidence Synthesis, Pakistan Institute of Living and Learning, Karachi, Pakistan.
¹⁵ Department of Psychology, Middlesex University, London, UK.
¹⁶ Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Australia.
¹⁷ NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK.
¹⁸ Department of Applied Health Sciences, University of Birmingham, Birmingham, UK.
¹⁹ Division of Population Health, Health Services Research & Primary Care, Manchester, UK.
²⁰ Institute of Psychiatry, Punjab, Pakistan.
²¹ Community Medicine, Karachi Medical and Dental College, Karachi, Pakistan.
²² Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
²³ Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
²⁴ Department of Psychiatry, Sir Cowasjee Jehangir Institute, Hyderabad, Pakistan.
²⁵ Department of Applied Psychology, Bahauddin Zakariya University, Multan, Pakistan.
²⁶ IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia.
²⁷ Centre for Adolescent Health, Murdoch's Children's Research Institute, Melbourne, Australia.
²⁸ School of Health & Wellbeing, University of Glasgow, Glasgow, UK.
²⁹ Five Areas, Glasgow, UK.
³⁰ Pakistan Institute of Living and Learning, Karachi, Pakistan.

PMID: 40940081
PMCID: PMC12426884
DOI: 10.1136/bmj-2024-083272

Randomized Controlled Trial

Effectiveness of YCMAP (youth culturally adapted manual assisted problem solving) intervention in adolescents after self-harm in Pakistan: multicentre, randomised controlled trial

Nusrat Husain et al. BMJ. 2025.

. 2025 Sep 12:390:e083272.

doi: 10.1136/bmj-2024-083272.

Authors

Affiliations

¹ Division of Psychology and Mental Health, The University of Manchester School of Health Sciences, Manchester, UK.
² Global Centre for Research on Mental Health Inequalities, Mersey Care NHS Foundation Trust, Prescot, UK.
³ Division of Neuro-Cognitive Disorder, Older Adults Mental Health, Pakistan Institute of Living and Learning, Karachi, Pakistan.
⁴ Division of Mood Disorder, Pakistan Institute of Living and Learning, Karachi, Pakistan.
⁵ Dr Ziauddin Hospital, Karachi, Pakistan.
⁶ Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
⁷ Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁸ Science and Technology Studies, University College London, London, UK.
⁹ Manchester Global Foundation, Manchester, UK.
¹⁰ Faculty of Health and Life Sciences, University of Liverpool, Liverpool UK.
¹¹ Statsconsultancy, Amersham, UK.
¹² Division of Biostatistics, Pakistan Institute of Living and Learning, Karachi, Pakistan.
¹³ Division of Child and Adolescents, Pakistan Institute of Living and Learning, Karachi, Pakistan.
¹⁴ Department of Evidence Synthesis, Pakistan Institute of Living and Learning, Karachi, Pakistan.
¹⁵ Department of Psychology, Middlesex University, London, UK.
¹⁶ Department of General Practice and Primary Care, Melbourne Medical School, University of Melbourne, Australia.
¹⁷ NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, UK.
¹⁸ Department of Applied Health Sciences, University of Birmingham, Birmingham, UK.
¹⁹ Division of Population Health, Health Services Research & Primary Care, Manchester, UK.
²⁰ Institute of Psychiatry, Punjab, Pakistan.
²¹ Community Medicine, Karachi Medical and Dental College, Karachi, Pakistan.
²² Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
²³ Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
²⁴ Department of Psychiatry, Sir Cowasjee Jehangir Institute, Hyderabad, Pakistan.
²⁵ Department of Applied Psychology, Bahauddin Zakariya University, Multan, Pakistan.
²⁶ IMPACT Strategic Research Centre, School of Medicine, Deakin University, Geelong, Australia.
²⁷ Centre for Adolescent Health, Murdoch's Children's Research Institute, Melbourne, Australia.
²⁸ School of Health & Wellbeing, University of Glasgow, Glasgow, UK.
²⁹ Five Areas, Glasgow, UK.
³⁰ Pakistan Institute of Living and Learning, Karachi, Pakistan.

PMID: 40940081
PMCID: PMC12426884
DOI: 10.1136/bmj-2024-083272

Abstract

Objective: To evaluate the clinical effectiveness of the YCMAP intervention (Youth Culturally Adapted Manual Assisted Problem Solving) for adolescents after self-harm in Pakistan.

Design: Multicentre, randomised controlled trial that compared YCMAP with enhanced treatment as usual.

Settings: General practices, emergency departments, medical wards of participating hospitals, and community centres across Karachi, Hyderabad, Lahore, Multan, and Rawalpindi.

Participants: Adolescents with a recent history of self-harm identified at participating health centres by treating physicians between 5 November 2019 and 31 August 2021.

Intervention: The YCMAP group received up to 10 treatment sessions over three months; the intervention was based on the principles of cognitive behaviour therapy.

Main outcome measure: The primary outcome was the repetition of self-harm at 12 months after randomisation. Secondary outcomes were distress, hopelessness, suicidal ideation, and health related quality of life at three, six, nine, and 12 months after randomisation. Participants' satisfaction with the services was assessed at three and 12 months after randomisation.

Results: This trial was conducted between November 2019 and February 2023 and included 684 adolescents randomised to YCMAP (n=342) or enhanced treatment as usual (n=342). The YCMAP group had a significantly lower risk of self-harm repetition than the enhanced treatment as usual group at 12 months after randomisation (odds ratio 0.20, 95% confidence interval 0.06 to 0.70, P=0.006). YCMAP participants showed a statistically significant reduction in distress, hopelessness, and suicidal ideation at three months, but these differences were not statistically significant at 12 months. YCMAP participants also reported significantly better quality of life and satisfaction with services at three months, with these effects sustained at all follow-up points.

Conclusion: The YCMAP intervention was shown to be beneficial in self-harm prevention among adolescents. Further research and replication of findings in diverse settings are recommended to strengthen the evidence base for this public health intervention.

Trial registration: ClinicalTrials.gov NCT04131179 and ISRCTN registry ISRCTN57325925.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the Foreign, Commonwealth and Development Office, the UK Medical Research Council, the National Institute for Health Research and the Wellcome Trust for the submitted work; NH has been a past trustee of the Pakistan Institute of Living and Learning, Abaseen Foundation UK, Lancashire Mind UK, and Manchester Global Foundation (MGF). He is an executive member of the Academic Faculty at the Royal College of Psychiatrists, London. He is a National Institute for Health Research (NIHR) senior investigator. He has attended educational events organised by various pharmaceutical industries. NC is CEO of the Pakistan Institute of Living and Learning, 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 honorary professor of psychiatry, Dow University of Health Sciences. She is chief investigator and co-investigator for a number of research projects funded by various grant bodies such as the Medical Research Council, Welcome Trust, NIHR, and Global Challenges Research Fund. NC was previously a trustee of the Pakistan Institute of Living and Learning. IBC has given lectures or advice to Eli Lilly, Bristol Myers Squibb, Lundbeck, Astra Zeneca, and Janssen pharmaceuticals for which he or his employing institution have been reimbursed, outside the submitted work. The authors declare no conflicts of interest associated with this trial.

Figures

**Fig 1**
CONSORT (consolidated standards of reporting trials) flow diagram. YCMAP=youth culturally adapted manual assisted problem solving. *Two participants reconnected at nine months in YCMAP group. †Three participants reconnected at 12 months in YCMAP group. ‡Three participants reconnected at 12 months in enhanced treatment as usual group

See this image and copyright information in PMC

References

1. WHO. Suicide worldwide in 2019: global health estimates. 2021. Available at: https://www.who.int/publications/i/item/9789240026643
1. Knipe D, Padmanathan P, Newton-Howes G, Chan LF, Kapur N. Suicide and self-harm. Lancet 2022;399:1903-16. 10.1016/S0140-6736(22)00173-8 - DOI - PubMed
1. Vijayakumar L, Armstrong G. Surveillance for self-harm: an urgent need in low-income and middle-income countries. Lancet Psychiatry 2019;6:633-4. 10.1016/S2215-0366(19)30207-X - DOI - PubMed
1. Shekhani SS, Perveen S, Hashmi DE, Akbar K, Bachani S, Khan MM. Suicide and deliberate self-harm in Pakistan: a scoping review. BMC Psychiatry 2018;18:44. 10.1186/s12888-017-1586-6 - DOI - PMC - PubMed
1. Kinchin I, Doran CM, Hall WD, Meurk C. Understanding the true economic impact of self-harming behaviour. Lancet Psychiatry 2017;4:900-1. 10.1016/S2215-0366(17)30411-X - DOI - PubMed

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Effectiveness of YCMAP (youth culturally adapted manual assisted problem solving) intervention in adolescents after self-harm in Pakistan: multicentre, randomised controlled trial

Affiliations

Effectiveness of YCMAP (youth culturally adapted manual assisted problem solving) intervention in adolescents after self-harm in Pakistan: multicentre, randomised controlled trial

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

Associated data

LinkOut - more resources

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Medical