Strengths and limitations
suicidal ideation, self-harm
SECONDARY
To the best of our knowledge, this was the largest therapist-delivered self-harm and suicide prevention trial across the world, with a high retention rate at a long-term follow-up. However, in most low-income settings (including Pakistan) access to trained mental health professionals/therapists is limited particularly in rural settings, telehealth solutions can address such challenges related to access. Mental health professionals in these settings may also consider how best to engage and train other allied health professionals such as nurses, and community health workers in the delivery of suicide prevention interventions or components of these interventions. Participants were recruited from a variety of settings (including primary care settings) across Pakistan, increasing the likelihood of the generalizability of findings. Moreover, the use of a detailed semi-structured tool (SASII) to assess the primary outcome, structured validated instruments to assess secondary outcomes, regular training, rigorous arrangements for supervision, and fidelity assessment have increased the validity of trial findings. In addition, a large sample size, with long-term follow-up is also a strength of the trial. However, since the risk of self-harm in those with suicidal ideation increases with time, therefore a longer-term follow-up is recommended. There was a disparity between the self-harm repetition rate expected based on sample size calculation and the repetition rate observed in the trial. A trial with an even larger sample size would be required to detect such a small difference observed in this study. Moreover, the CMAP intervention focused on different components that are likely to reduce social stigma and improve the awareness of self-harm and its prevention such as psychoeducation about the motivations behind self-harm episodes, emotional consequences of the episode, importance of seeking professional help etc. Future trials of CMAP intervention may consider assessing change in participants’ attitude and behaviours towards self-harm and suicide at end of intervention.Further research is also needed to explore the role of brief follow-up contact, such as using postcards in low resource settings. The clinical staging model which involves multiple intervention stages have been found to be effective [