Cost-Effectiveness of a Culturally Adapted Manual-Assisted Brief Psychological Intervention for Self-Harm in Pakistan: A Secondary Analysis of the Culturally Adapted Manual-Assisted Problem-Solving Training Randomized Controlled Trial



Self-harm is a serious public health problem. A culturally adapted manual-assisted problem-solving training (C-MAP) intervention improved and sustained the reduction in suicidal ideation, hopelessness, and depression compared with treatment as usual (TAU) alone. Here, we evaluate its cost-effectiveness.


Patients admitted after an episode of self-harm were randomized individually to either C-MAP plus TAU or TAU alone in Karachi. Improvement in health-related quality-adjusted life years (QALYs) was measured using the Euro Qol-5D-3L instrument at baseline and at 3 months and 6 months after randomization. The primary economic outcome was health service cost per QALY gained as the incremental cost-effectiveness ratio, based on 2019 US dollars and a 6-month time horizon. Nonparametric bootstrapping was used to assess uncertainties, and sensitivity analysis to examine the impact of hospitalization costs.


A total of 108 and 113 participants were enrolled among the intervention and standard arms, respectively. The intervention resulted in 0.04 more QALYs (95% confidence interval [CI] 0.00–0.08) 6 months after enrolment. The mean cost per participant in the intervention arm was US $1001 (95% CI 968–1031), resulting in an incremental cost of the intervention of US $640 (95% CI 595–679). The incremental cost-effectiveness ratio for the C-MAP intervention versus TAU was US $16 254 (95% CI 7116–99 057) per QALY gained. The probability that C-MAP is cost-effective was between 66% and 83% for cost-effective thresholds between US $20 000 and US $30 000. Cost-effectiveness results remained robust to sensitivity analyses.


C-MAP may be a valuable self-harm intervention. Further studies with longer follow-up and larger sample sizes are needed to draw reliable conclusions.


Mohsin H. Alvi Tinevimbo Shiri Nasir Iqbal Mohammed Omair Husain Imran Chaudhry Suleman Shakoor Sami Ansari Tayyeba Kiran Nasim Chaudhry Nusrat Husain

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