PDF(Pubmed)
Abstract：
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.
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).
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.
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.
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).
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.
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.
摘要：
自我伤害是自杀死亡的重要预测因素。需要在文化上适当的策略来预防自残和自杀，但来自低收入和中等收入国家（LMICs）的证据非常有限。这项研究旨在调查文化适应的手动辅助问题解决干预（CMAP）对自我伤害后出现的患者的有效性。
这是一个盲点,多中心随机对照试验。研究地点都是参与的急诊科，卡拉奇综合医院和初级保健中心的病房，拉合尔,拉瓦尔品第,白沙瓦,还有Quetta,巴基斯坦。在自我伤害发作后（n=901）出现在参与招募地点的患者进行了评估，并随机分配（1：1）到两个组中的一个；CMAP照常加强治疗（E-TAU）或E-TAU。干预(CMAP)是手动辅助的，认知行为疗法（CBT）-知情的问题聚焦疗法，包括六个一对一的会议，为期三个月。随机化后12个月自我伤害的重复是主要结局，次要结局包括自杀意念，绝望,抑郁症,健康相关生活质量（QoL），应对资源，以及对收到的服务的满意度，在基线评估，3-,6-，9-，和随机化后12个月。该审判已在ClinicalTrials.gov上注册。NCT02742922（2016年4月）。
我们筛选了3786名符合资格的患者和901名符合资格的患者。同意的患者被随机分配到CMAP+E-TAU组(n=440)和E-TAU组(N=461).在随机化后12个月，CMAP加E-TAU的自我伤害重复次数（n=17）低于E-TAU组（n=23），但差异无统计学意义(p=0.407)。其他结局（包括自杀意念）在统计学和临床上显着降低（-3.6（-4.9，-2.4）），抑郁症（-7.1（-8.7，-5.4）），绝望（-2.6（-3.4，-1.8），与E-TAU组相比，CMAP加E-TAU组完成干预后，与健康相关的QoL和应对资源有所改善。除自杀意念和绝望外，所有结果在12个月的随访中均持续有效。关于自杀意念和绝望，干预组的参与者得分低于E-TAU组，但差异无统计学意义，尽管在12个月的随访中，两组参与者都属于低风险类别。两个方面的改善可以通过加强护理在预防自杀中的既定作用来解释。
自杀意念被认为是预防自杀的重要目标，因此,应考虑将CMAP干预纳入自我伤害和自杀预防指南。鉴于E-TAU臂的改进，定期接触等简短干预措施的潜在使用需要进一步探索。
这是一个盲点,多中心随机对照试验。研究地点都是参与的急诊科，卡拉奇综合医院和初级保健中心的病房，拉合尔,拉瓦尔品第,白沙瓦,还有Quetta,巴基斯坦。在自我伤害发作后（n=901）出现在参与招募地点的患者进行了评估，并随机分配（1：1）到两个组中的一个；CMAP照常加强治疗（E-TAU）或E-TAU。干预(CMAP)是手动辅助的，认知行为疗法（CBT）-知情的问题聚焦疗法，包括六个一对一的会议，为期三个月。随机化后12个月自我伤害的重复是主要结局，次要结局包括自杀意念，绝望,抑郁症,健康相关生活质量（QoL），应对资源，以及对收到的服务的满意度，在基线评估，3-,6-，9-，和随机化后12个月。该审判已在ClinicalTrials.gov上注册。NCT02742922（2016年4月）。
我们筛选了3786名符合资格的患者和901名符合资格的患者。同意的患者被随机分配到CMAP+E-TAU组(n=440)和E-TAU组(N=461).在随机化后12个月，CMAP加E-TAU的自我伤害重复次数（n=17）低于E-TAU组（n=23），但差异无统计学意义(p=0.407)。其他结局（包括自杀意念）在统计学和临床上显着降低（-3.6（-4.9，-2.4）），抑郁症（-7.1（-8.7，-5.4）），绝望（-2.6（-3.4，-1.8），与E-TAU组相比，CMAP加E-TAU组完成干预后，与健康相关的QoL和应对资源有所改善。除自杀意念和绝望外，所有结果在12个月的随访中均持续有效。关于自杀意念和绝望，干预组的参与者得分低于E-TAU组，但差异无统计学意义，尽管在12个月的随访中，两组参与者都属于低风险类别。两个方面的改善可以通过加强护理在预防自杀中的既定作用来解释。
自杀意念被认为是预防自杀的重要目标，因此,应考虑将CMAP干预纳入自我伤害和自杀预防指南。鉴于E-TAU臂的改进，定期接触等简短干预措施的潜在使用需要进一步探索。
