Skip to main content
SpringerLink
Log in

Psychosocial interventions for self-harm in low-income and middle-income countries: systematic review and theory of change

  • Original Paper
  • Published:
Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Whitlock J, Muehlenkamp J, Eckenrode J, Purington A, Abrams GB, Barreira P, Kress V (2013) Nonsuicidal self-injury as a gateway to suicide in young adults. J Adolesc Health 52(4):486–492

    Article  Google Scholar 

  2. World Health Organization (2014) Preventing suicide: a global imperative. World Health Organization

  3. Aggarwal S, Patton G, Reavley N, Sreenivasan SA, Berk M (2017) Youth self-harm in low- and middle-income countries: systematic review of the risk and protective factors. Int J Soc Psychiatry 63(4):359–375. https://doi.org/10.1177/0020764017700175

    Article  PubMed  Google Scholar 

  4. Knipe D, Williams AJ, Hannam-Swain S, Upton S, Brown K, Bandara P, Chang S-S, Kapur N (2019) Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: a systematic review and meta-analysis. PLOS Med 16(10):e1002905. https://doi.org/10.1371/journal.pmed.1002905

    Article  PubMed  PubMed Central  Google Scholar 

  5. Hawton K, Witt KG, Salisbury TLT, Arensman E, Gunnell D, Hazell P, Townsend E, van Heeringen K (2016) Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev 12(5):CD012189. https://doi.org/10.1002/14651858.CD012189

    Article  Google Scholar 

  6. Hawton K, Witt KG, Salisbury TLT, Arensman E, Gunnell D, Townsend E, van Heeringen K, Hazell P (2015) Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 21(12):CD012013. https://doi.org/10.1002/14651858.CD012013

    Article  Google Scholar 

  7. Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V (2017) Psychological treatments for the world: lessons from low-and middle-income countries. Annu Rev Clin Psychol 13:149–181

    Article  Google Scholar 

  8. De Silva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund C, Patel V (2014) Theory of change: a theory-driven approach to enhance the Medical Research Council’s framework for complex interventions. Trials 15(1):267

    Article  Google Scholar 

  9. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151(4):264–269

    Article  Google Scholar 

  10. England MJ, Butler AS, Gonzalez ML (2015) Committee on developing evidence-based standards for psychosocial interventions for mental disorders, board on health sciences policy, & institute of medicine. Psychosocial interventions for mental and substance use disorders: a framework for establishing evidence-based standards. National Academies Press (US)

  11. Chorpita BF, Becker KD, Daleiden EL (2007) Understanding the common elements of evidence-based practice: Misconceptions and clinical examples. J Am Acad Child Adolesc Psychiatry 46(5):647–652

    Article  Google Scholar 

  12. Becker KD, Lee BR, Daleiden EL, Lindsey M, Brandt NE, Chorpita BF (2015) The common elements of engagement in children’s mental health services: which elements for which outcomes? J Clin Child Adolesc Psychol 44(1):30–43

    Article  Google Scholar 

  13. Ramaiya MK, McLean C, Regmi U, Fiorillo D, Robins CJ, Kohrt BA (2018) A dialectical behavior therapy skills intervention for women with suicidal behaviors in rural Nepal: a single-case experimental design series. J Clin Psychol 74(7):1071–1091

    Article  Google Scholar 

  14. Husain N, Afsar S, Ara J, Fayyaz H, ur Rahman R, Tomenson B, Hamirani M, Chaudhry N, Fatima B, Husain M (2014) Brief psychological intervention after self-harm: randomised controlled trial from Pakistan. Br J Psychiatry 204(6):462–470

    Article  Google Scholar 

  15. Alavi A, Sharifi B, Ghanizadeh A, Dehbozorgi G (2013) Effectiveness of cognitive-behavioral therapy in decreasing suicidal ideation and hopelessness of the adolescents with previous suicidal attempts. Iran J Pediatr 23(4):467

    PubMed  PubMed Central  Google Scholar 

  16. Hassanian-Moghaddam H, Sarjami S, Kolahi A-A, Carter GL (2011) Postcards in Persia: randomised controlled trial to reduce suicidal behaviours 12 months after hospital-treated self-poisoning. Br J Psychiatry 198(4):309–316

    Article  Google Scholar 

  17. Marasinghe RB, Edirippulige S, Kavanagh D, Smith A, Jiffry MT (2012) Effect of mobile phone-based psychotherapy in suicide prevention: a randomized controlled trial in Sri Lanka. J Telemed telecare 18(3):151–155

    Article  Google Scholar 

  18. Perera ER, Kathriarachchi ST (2011) Problem—solving counseling as a therapeutic tool on youth suicidal behavior in the suburban population in Sri Lanka. Indian J Psychiatry 53(1):30

    Article  Google Scholar 

  19. Hassanian-Moghaddam H, Sarjami S, Kolahi AA, Lewin T, Carter G (2017) Postcards in Persia: a twelve to twenty-four month follow-up of a randomized controlled trial for hospital-treated deliberate self-poisoning. Arch Suicide Res 21(1):138–154. https://doi.org/10.1080/13811118.2015.1004473

    Article  PubMed  Google Scholar 

  20. Mousavi SG, Amini M, Mahaki B, Bagherian-Sararoudi R (2016) Effect of phone call versus face-to-face follow-up on recurrent suicide attempts prevention in individuals with a history of multiple suicide attempts. Adv Biomed Res 5:184. https://doi.org/10.4103/2277-9175.190990

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wei S, Liu L, Bi B, Li H, Hou J, Tan S, Chen X, Chen W, Qin X (2013) An intervention and follow-up study following a suicide attempt in the emergency departments of four general hospitals in Shenyang. China. Crisis 34(2):107–115. https://doi.org/10.1027/0227-5910/a000181

    Article  PubMed  Google Scholar 

  22. Armitage CJ, Rahim WA, Rowe R, O’Connor RC (2016) An exploratory randomised trial of a simple, brief psychological intervention to reduce subsequent suicidal ideation and behaviour in patients admitted to hospital for self-harm. Br J Psychiatry 208(5):470–476

    Article  Google Scholar 

  23. Law YW, Yip PS, Lai CC, Kwok CL, Wong PW, Liu KS, Ng PW, Liao CW, Wong TW (2016) A pilot study on the efficacy of volunteer mentorshipfor young adults with self-harm behaviors using a quasi-experimental design. Crisis. 37(6):415–426. https://doi.org/10.1027/0227-5910/a000393

    Article  PubMed  Google Scholar 

  24. Raj MAJ, Kumaraiah V, Bhide AV (2001) Cognitive-behavioural intervention in deliberate self-harm. Acta Psychiatr Scand 104(5):340–345

    Article  CAS  Google Scholar 

  25. Fleischmann A, Bertolote JM, Wasserman D, De Leo D, Bolhari J, Botega NJ, De Silva D, Phillips M, Vijayakumar L, Värnik A (2008) Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. Bull World Health Organ 86:703–709

    Article  Google Scholar 

  26. Mousavi S, Rabiei Z, Maracy MR, Ebrahimi A, Sharbafchi MR (2014) The efficacy of telephonic follow up in prevention of suicidal reattempt in patients with suicide attempt history. Adv Biomed Res 3:198. https://doi.org/10.4103/2277-9175.142043

    Article  PubMed  PubMed Central  Google Scholar 

  27. McMyler C, Pryjmachuk S (2008) Do “no-suicide” contracts work? J Psychiatr Ment Health Nurs 15:512–522. https://doi.org/10.1111/j.1365-2850.2008.01286.x

    Article  CAS  PubMed  Google Scholar 

  28. Stanley B, Brown G, Brent DA, Wells K, Poling K, Curry J, Kennard BD, Wagner A, Cwik MF, Klomek AB (2009) Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. J Am Acad Child Adolesc Psychiatry 48(10):1005–1013

    Article  Google Scholar 

  29. Naeem F, Ayub M, Gobbi M, Kingdon D (2009) Development of Southampton Adaptation Framework for CBT (SAF-CBT): a framework for adaptation of CBT in non-western culture. J Pak Psychiatr Soc 6(2):79–84

    Google Scholar 

  30. Gøtzsche PC, Gøtzsche PK (2017) Cognitive behavioural therapy halves the risk of repeated suicide attempts: systematic review. J R Soc Med 110(10):404–410

    Article  Google Scholar 

  31. World Health Organization (2016) mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings: mental health gap action programme (mhGAP): Version 2.0. World Health Organization, Geneva. https://www.ncbi.nlm.nih.gov/books/NBK390815/

  32. Castro FG, Barrera M Jr, Holleran Steiker LK (2010) Issues and challenges in the design of culturally adapted evidence-based interventions. Annu Rev Clin Psychol 6:213–239. https://doi.org/10.1146/annurev-clinpsy-033109-132032

    Article  PubMed  PubMed Central  Google Scholar 

  33. Vaiva G, Ducrocq F, Meyer P, Mathieu D, Philippe A, Libersa C, Goudemand M (2006) Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: randomised controlled study. BMJ 332(7552):1241–1245

    Article  Google Scholar 

  34. Naslund J, Aschbrenner K, Araya R, Marsch L, Unützer J, Patel V, Bartels S (2017) Digital technology for treating and preventing mental disorders in low-income and middle-income countries: a narrative review of the literature. Lancet Psychiatry. https://doi.org/10.1016/S2215-0366(17)30096-2

    Article  PubMed  PubMed Central  Google Scholar 

  35. Motto JA, Bostrom AG (2001) A randomized controlled trial of postcrisis suicide prevention. Psychiatr Serv 52(6):828–833. https://doi.org/10.1176/appi.ps.52.6.828

    Article  CAS  PubMed  Google Scholar 

  36. Chowdhary N, Sikander S, Atif N, Singh N, Ahmad I, Fuhr DC, Rahman A, Patel V (2014) The content and delivery of psychological interventions for perinatal depression by non-specialist health workers in low and middle income countries: a systematic review. Best Pract Res Clin Obstetr Gynaecol 28(1):113–133

    Article  Google Scholar 

  37. Prochaska JO, DiClemente CC (1983) Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol 51(3):390

    Article  CAS  Google Scholar 

  38. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, Britten N, Roen K, Duffy S (2006) Guidance on the conduct of narrative synthesis in systematic reviews. A product from the ESRC methods programme Version 1:b92

  39. Berk MS, Henriques GR, Warman DM, Brown GK, Beck AT (2004) A cognitive therapy intervention for suicide attempters: An overview of the treatment and case examples. Cogn Behav Pract 11(3):265–277

    Article  Google Scholar 

  40. Andrews G, Hunt C (1998) 15. Treatmets that workin anxiety disorders. Med J Aust 168(12):628–634

    Article  CAS  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

  1. Public Health Foundation of India (Centre for Chronic Conditions), New Delhi, India

    Shilpa Aggarwal

  2. Faculty of Health, School of Medicine, Deakin University, Geelong, Australia

    Shilpa Aggarwal

  3. Murdoch Children’s Research Institute (Centre for Adolescent Health), Victoria, Australia

    George Patton

  4. IMPACT-The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia

    Michael Berk

  5. Department of Psychiatry, Orygen (Centre for Youth Mental Health), Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia

    Michael Berk

  6. Harvard T H Chan School of Public Health, Global Health and Social Medicine, Boston, MA, USA

    Vikram Patel

Authors
  1. Shilpa Aggarwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. George Patton
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michael Berk
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vikram Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Shilpa Aggarwal.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Availability of data and material

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.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

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

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00127-020-02005-5

Keywords

Search

Navigation