Abstract
Purpose
To synthesise the evidence on effectiveness, acceptability and the delivery mechanisms of psychosocial interventions for self-harm in low and middle income countries and to develop a pathway of change specific for self-harm interventions.
Method
Studies reporting one or more patient or implementation outcomes of a psychosocial intervention targeting self-harm and conducted in low- and middle-income countries were included. Taxonomy of treatment components and a theory of change map was created using information from the studies.
Results
We identified thirteen studies including nine randomised controlled trials (RCT), three non-RCTs, and a single experimental case design study. A single study using postcard contact and another using cognitive behaviour therapy (CBT) reported a reduction in self-harm attempts. Suicidal ideations were significantly reduced with CBT, volitional help sheets and postcard contact in different studies. Suicide risk assessment, problem solving and self-validation were the most frequently used elements in interventions. Goal-setting was the technique used most commonly. Cultural adaptations of psychotherapies were used in two studies. High attrition rates in psychotherapy trials, limited benefit of the delivery of treatment by non-specialist providers, and variable benefit observed using phone contact as a means to deliver intervention were other important findings.
Conclusion
There were no strong positive findings to draw definitive conclusions. Limited availability and evidence for culturally adapted interventions in self-harm, lack of evaluation of task sharing using evidence based interventions as well as a dearth in evaluation and reporting of various intervention delivery models in low- and middle-income countries were major literature gaps.
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Acknowledgements
The authors acknowledge the support of Sufiya Shaikh in helping with the study search for the systematic review
Funding
The current work is supported by the Wellcome Trust- India Alliance Research Fellowship (IA/CPHE/16/1/502664) awarded to SA.
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The authors declare that they have no conflict of interest.
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The data reported in this manuscript were obtained from publicly available data from published studies searched using databases mentioned in the manuscript. The variables and relationships examined in the present article have not been examined in any previous or current articles, or to the best of our knowledge in any papers that will be under review soon.
Appendix
Appendix
Self-harm specific elements [27, 28]
Chain analysis
Step-by-step approach to objectively look at the events that led to self-harm to identify vulnerabilities and activating events.
Safety and crisis plan
Plan with prioritized specific set of coping strategies for suicidal crisis, includes warning signs, and contact details of people to be contacted in crisis and helpline numbers.
Developing reasons for living and hope
Identifying personal reasons to live, creating a hope kit that acts as a memory aid in crisis and is a concrete implementation of reasons to be alive.
Suicidal contracts
An agreement, usually written, between a mental health service user and a clinician, whereby the service user pledges not to harm himself or herself.
Relapse prevention
An ‘‘in vivo’’ guided imagery technique to test the efficacy of skills acquired during therapy and coping capabilities in preventing suicidal behaviour in the future.
Suicide risk screening
Assessment to identify the likelihood of someone trying to take their own life.
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Aggarwal, S., Patton, G., Berk, M. et al. Psychosocial interventions for self-harm in low-income and middle-income countries: systematic review and theory of change. Soc Psychiatry Psychiatr Epidemiol 56, 1729–1750 (2021). https://doi.org/10.1007/s00127-020-02005-5
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DOI: https://doi.org/10.1007/s00127-020-02005-5