Introduction
Suicidal ideation, planning and attempts are one of the leading public health issues among adolescents worldwide (World Health Organisation, 2022). Approximately 700,000 people die by suicide annually with suicide rates over-represented in adolescents and young adults. Whilst children and young adolescents (≤15 years of age) exhibit the lowest global suicide rates, suicide rates steadily increase in individuals over 15 years of age, with the highest absolute (not relative numbers per age group) numbers of individuals who die by suicide aged between 15 and 29 years, (Bachmann Reference Bachmann2018). In Pakistan, age standardised suicide rates per 100,000 individuals for adolescents and young adults (10–24 years) are noted as 13.5 for males and 6.2 for females (World Health Organisation, 2022). Risk of suicide in this age cohort is associated with family conflict, lower levels of educational attainment and socioeconomic status (Eslava et al. Reference Eslava, Martínez-Vispo, Villanueva-Blasco, Errasti and Al-Halabí2023; Hughes et al. Reference Hughes, Liu and Qin2025), with clinical factors including a prior history of suicide attempts and/or acts of self-harm, the presence of a mental disorder (i.e. recurrent depressive disorder), and high levels of impulsivity (Abdullah et al. Reference Abdullah, Khalily, Ahmad and Hallahan2018; Reference Abdullah, Khalily, Ruocco and Hallahan2023; Moitra et al. Reference Moitra, Santomauro, Degenhardt, Collins, Whiteford, Vos and Ferrari2021).
Studies utilising psychotherapeutic interventions to reduce suicidal ideation and behaviours have generally encompassed a combination of techniques, with meta-analytic data demonstrating a lack of benefit for psychotherapeutic interventions for suicidality in this age cohort (Gaynor et al. Reference Gaynor, O’Reilly, Redmond, Nealon, Twomey and Hennessy2023). However, cognitive behavioural therapy principles have been employed for “skill-building” in adolescent populations (Ougrin et al. Reference Ougrin, Tranah, Stahl, Moran and Asarnow2015; Grażka and Strzelechi Reference Grażka and Strzelecki2023). Recent novel interventions utilised in this age cohort with the aim of reducing suicidality have included coping and support training (CAST), and care, assess respond and empower (CARE) programmes with the broad aim of increasing coping skills, and consequently reducing levels of suicidality have shown promising preliminary evidence (Randell et al. Reference Randell, Eggert and Pike2001; Thompson et al. Reference Thompson, Eggert, Randell and Pike2001; Hooven et al. Reference Hooven, Herting and Snedker2010). An example of such an interventional study utilising a culturally adapted manual-assisted problem-solving intervention was conducted in general hospitals and primary care centres in Pakistan (i.e. Karachi, Lahore, Rawalpindi, Peshawar, and Quetta) and demonstrated potential efficacy of this intervention regarding suicidal ideation in particular, with a non-significant reduction in self-harm additionally noted (Husain et al. Reference Husain, Kiran, Chaudhry, Williams, Emsley, Arshad, Ansari, Bassett, Bee, Bhatia, Chew-Graham, Husain, Irfan, Khaliq, Minhas, Naeem, Naqvi, Nizami, Noureen, Panagioti, Rasool, Saeed, Bukhari, Tofique, Zadeh, Zafar and Chaudhry2023). Cultural adaptation of psychotherapies are demonstrated to be effective with over twenty different frameworks noted for cognitive behaviour therapy for example (Naeem et al. Reference Naeem, Sajid, Naz and Phiri2023). Didactic interventions incorporate behavioural therapy and the provision of psychoeducation to adaptive coping mechanisms, controlling adverse or triggering external stimuli, assessing participants’ progress over time longitudinally and the provision of additional psychotherapeutic input pertaining to the utilisation of appropriate coping strategies (Lee and Kourgiantakis Reference Lee and Kourgiantakis2023) may also play a therapeutic role in reducing suicidal ideation and behaviours.
Consequently, the current study incorporates a didactic approach based on religious teachings and cultural milieu, known as a Culturally Adapted Didactic Strategy for Suicidality (CADS-S) with the aim of reducing suicidal ideation, impulsivity and psychological distress. This didactic model has previously been utilised in Pakistan for managing psychological distress Zafar and Khalily Reference Zafar and Khalily2015), but has not previously been utilised with the aim of reducing suicidal ideation and behaviours.
Methods
Study design
This was a six-week single-blind randomised controlled trial (Registered at: ClinicalTrials.gov: NCT05324670) in which participants aged 16–20 years of age were included based on the presence of suicidality. Researchers but not participants were blind to group allocation. The study was conducted over a 2-years, 2-months period between December 2021 and February 2024 with participants recruited from nine educational institutions located in Peshawar, Khyber Pakhtunkhwa, Pakistan. These institutions only included male students. Advertisements were placed in these institutions with contact details provided for the research team. Participants who contacted the research team were provided with a participant information leaflet and were contacted between one and two weeks later to ascertain if they wanted to participate in the study. Ethical approval was attained prior to study commencement from the Departmental Ethics Committee “Board for Advance Studies and Research (BASR)” at the International Islamic University Islamabad (F. No. IIU/2021-Exams-6,511). Participants were not actively attending a mental health service (either outpatient or inpatient care). For participants under 18 years of age, informed consent was attained from participants’ parent(s) in addition to assent from study participants. All researchers working in this study attained supervision on clinical trial management and completed good clinical practices (GCP) training. Due to the study being conducted in these educational institutions (high school and foundation year university courses), individuals over 20 years of age were unavailable for inclusion.
Participants
Participants were included if they (i) expressed suicidal ideation to a peer or family member, (ii) engaged in self-harm within six months of study participation and (iii) demonstrated suicidal ideation, impulsivity and distress as indicated by psychometric scores ≥20 on the Beck Scale for Suicidal Ideation (BSS), ≥90 on the Barratt Impulsivity Scale (BIS-II), and ≥80 on the Depression Anxiety Stress Scale (DASS-21). Individuals were excluded if they fulfilled criteria for a Diagnostic and Statistical Manual-5 (DSM–5) mental disorder, including substance use disorder (including alcohol), were unable to engage in study procedures at the study site due to transport difficulties or were actively attending a mental health service (self-reported at screening interview). Individuals who fulfilled criteria for a DSM-5 mental disorder were informed of their diagnosis and advised regarding engagement in appropriate management strategies (i.e. primary care, mental health or addiction services supports). Individuals unable to engage due to transportation difficulties, were provided with advice on how to engage with appropriate supports.
Culturally adapted didactic strategy for suicidality (CADS-S)
This 12-session programme (two 45–50 minute sessions per week), incorporates cognitive behavioural techniques and problem-solving skills (see Appendix 1 for further detail on sessions). In addition, participants complete several work-sheet activities involving: (1) practising selflessness and kindness, (2) developing a consistent prayer routine, (3) offering supplications (duas) for various occasions, (4) cultivating good relationships with family and others and (5) distinguishing between positive and negative actions. CADS-S was delivered by a qualified clinical psychologist who had at least 5-years’ experience using psychotherapy in clinical settings (MA) but not specifically CADS-S, with weekly one-to-one supervision provided from a senior psychologist (MTK) with over 30 years of experience in the use of psychotherapy including didactic therapeutic interventions in this age cohort. Supervisory sessions supported case conceptualisation, goal formulation, facilitators of and barriers to achieving desirable behaviour, progress, and resolution of any potential difficulties during the intervention. If any participant became significantly distressed and/or described active suicidal intent during the course of a therapeutic session, they were supported in attaining further medical or psychiatric intervention(s).
Control intervention
Participants in the control arm were provided with reading material in the form of a leaflet detailing cognitive behaviour techniques and problem-solving skills on one occasion (i.e. general life skills including cultivating good relationships with family and others). Participants were invited to review the materials provided and were given time to clarify any aspects of the information provided (on the same day as the information was provided). No additional psychotherapeutic interventions were provided to the control group. All participants received a monthly call from a designated researcher to ensure their ongoing engagement with the research study.
Power analysis was conducted using G*Power calculator (Faul et al. Reference Faul, Erdfelder, Lang and Buchner2007), and was based on data in Pakistan relating to impulsivity and suicidal ideation in a similar age cohort (Moitra et al. Reference Moitra, Santomauro, Degenhardt, Collins, Whiteford, Vos and Ferrari2021). Consequently, a sample of 58 participants was required to provide 80% power (p < 0.05). To account for a potential dropout rate of 20%, 70 participants were initially recruited and randomised equally across both groups, with researchers blind to group allocation and subsequently not involved in data acquisition. Allocation was undertaken utilising a computer-generated block randomisation sequence.
Participants were randomly assigned to receive either CADS-S or the control intervention in a 1:1 ratio. Randomly permuted blocks of sizes 4 and 6 were utilised to ensure similar numbers of participants in each arm of the trial. Interventions were alongside “treatment as usual” (i.e. support from general practitioner), albeit no participants were attending mental health services.
Clinical assessments
At baseline, demographic data were attained from participants including age, gender, educational and/or vocational status, and socioeconomic status. In addition to screening, baseline and study-end data (6 weeks), participants were invited for follow-up six weeks post study intervention and engaged in a brief interview which included if there had been any episodes of self-harm during the study period. Psychometric instruments completed by the participant included:
Beck scale for suicidal ideation (BSS)
The BSS scale consists of 19 items and measures severity of suicidal ideation for each item on a 3-point Likert scale (range 0-2 on each item) (Beck et al. Reference Beck, Kovacs and Weissman1979). The adapted and translated Urdu version of this instrument has a Cronbach’s α = 0.86 (Ayub Reference Ayub2008).
Barratt impulsiveness scale (BIS-II)
The BIS-II consists of 30 items that describe attentional, motoric and non-planning impulsivity (Patton et al. Reference Patton, Stanford and Barratt1995), with each item measured utilising a 4-point Likert scale from rarely/never to almost/always. The adapted and translated version (Urdu) of this scale has a total Cronbach’s α = 0.87 (Attention: α = 0.63, Motoric: α = 0.77 and Non-Planning: α = 0.74) (Masood et al. Reference Masood, Kamran, Qaisar and Ashraf2018).
Depression anxiety and stress scale (DASS) - 21
The DASS-21 measures depressive and anxiety symptoms and levels of and stress (Lovibond and Lovibond 1966), and comprises 21 items, (range of 0–3 for each item). The Urdu translated version demonstrates a Cronbach’s alpha of 0.93 for the total scale with subscale scores of 0.84 (Depression), 0.86 (Anxiety), and 0.83 (Stress) (Aslam and Kamal Reference Aslam and Kamal2017).
The researcher scoring these assessments was blind to the intervention received by the participant.
Statistical analysis
The Statistical Package for Social Sciences, Version 23.0 (SPSS 23, SPSS Inc., IBM, New York, USA) was utilised for data analysis. Descriptive statistics including means, standard deviations, frequencies and percentages were utilised for the description of data on a range of categorical and continuous variables. Confirmation of data at both study-end and follow-up for all indices were undertaken utilising analysis of covariance (ANCOVA). Psychometric data at study end-point was compared to baseline data utilising paired t-tests and analysis of co-variance, which incorporated controlling for differences in baseline demographics. All three time-points (baseline, study end-point and follow-up) were compared utilising repeated measure analysis of co-variance (Wilks-Lambda statistic), with age controlled for. Partial eta-squared (ηp 2) was utilised to measure effect size, with 0.2–0.5 indicating a small effect, 0.5–0.8 indicating a moderate effect and >0.8 indicating a large effect. Intention-to-treat analysis was used for individuals who withdrew from the study prior to the final study visit. A Bonferroni correction was utilised due to multiple testing.
Results
Of the 150 individuals assessed for study inclusion, 41 (27.3%) individuals declined study participation, 34 (22.6%) individuals were unable to participate due to travel-related difficulties, and 5 (3.3%) fulfilled DSM-5 diagnostic criteria (major depressive disorder = 1, substance use disorder = 4) resulting in 70 study participants (see Figure 1). Demographic and clinical characteristics of study participants are displayed in Table 1. The age of the CADS group was marginally older (18.5 v 17.7 years) and displayed a higher level of suicidal ideation at baseline (28.7 v 23.0,t = 9.0, p < 0.01), with no other significant differences in a range of demographic or clinical symptoms evident. All participants had engaged in at least two acts of self-harm within the previous six months.
Figure 1. CONSORT flowchart.
Table 1. Demographic and clinical data
* Scoring based utilising the global network socioeconomic status index (GN-SESI) with scores of 0–32, 33–66 and 67–100 indicating low, middle and high socio-economic class (Alkire and Santos Reference Alkire and Santos2011).
Psychometric data are presented in Tables 2 and 3. Participants in the CADS cohort demonstrated a significant reduction in suicidal ideation compared to individuals in the control arm utilising repeated measure analysis (F = 33.2, p < 0.001, ηp 2 = 0.91), (controlling for baseline age – see Table 2). Findings of reduced suicidal ideation were confirmed for both study end (F = 148.2, p < 0.001, ηp 2 = 0.71) and at follow-up (F = 176.7, p < 0.001, ηp 2 = 0.74) controlling for both baseline suicidal ideation and age. Mean differences in data across the three time-points using ANCOVA are presented in Table 3.
Table 2. Psychometric data – difference is psychometric data between the CADS-S and control groups utilising repeated measures ANOVA
***p ≤ 0.001, **p ≤ 0.05; Age controlled for in analysis.
Table 3. Mean difference (MD) and standard error at Baseline, treatment ends (6 weeks) and follow-up after 12 weeks
p < 0.05*.
MD = Mean differences; SE = Standard Error.
BSS = Beck Scale for Suicidal ideation; BIS = Barratt Impulsivity Scale; DASS = Depression Anxiety Stress Scale.
Individuals in the CADS group additionally demonstrated reduced impulsivity symptoms and distress symptoms controlling for age compared to controls utilising repeated measures for all aspects of impulsivity (total, attentional, motoric and non-planning) and distress (total, depression, anxiety and stress) controlling for age (p < 0.001) (see Table 2), with mean differences displayed between the groups at the three-time points in Table 3.
No participants in the CADS group engaged in self-harm (irrespective of their history of self-harm) during the study period. However, three participants in the control group (with more than two prior acts of self-harm) engaged in self-harm and due to describing ongoing suicidal ideation were referred to (and agreed to attend) a local mental health centre (see Figure 1). No individuals died in the study and none required medical (non-psychiatric) intervention for self-harm during the study.
Sixty-three individuals (90%) completed all aspects of the study including the 12-week follow-up assessment (33 (47.2%) individuals from the CADS-S and 30 (42.8%) from the control group). There was no statistical difference in relation to the number of participants who completed the trial between the two groups, and none of the individuals who dropped-out of the study described adverse events or declined participation due to any study procedures. The mean and standard deviation of sessions attended in the CADS-S intervention was 6.5 (3.5).
Discussion
The current study examined the effectiveness of a CADS compared to a control intervention (reading material in the form of a leaflet detailing cognitive behaviour techniques and problem-solving skills on one occasion and monthly phone calls) in targeting elf-harm, suicidal ideation, impulsivity and psychological distress in a cohort of high-school Pakistani male adolescents. The findings indicated a significant reduction in suicidal ideations and behaviours, as well as improvements in impulsivity and psychological distress, compared to a matched control group.
This is the first study to utilise this particular intervention with the aim of reducing suicidality. The findings of reducing suicidal ideation and behaviours is consistent with a recent study in adolescents who had recently engaged in self-harm employing similar techniques (Husain et al. Reference Husain, Kiran, Chaudhry, Williams, Emsley, Arshad, Ansari, Bassett, Bee, Bhatia, Chew-Graham, Husain, Irfan, Khaliq, Minhas, Naeem, Naqvi, Nizami, Noureen, Panagioti, Rasool, Saeed, Bukhari, Tofique, Zadeh, Zafar and Chaudhry2023).
A significant reduction in impulsivity was noted with this intervention, including the three sub-components of impulsivity measured (attentional, motor, and non-planning). Our findings of reduced impulsivity are consistent with previous data where a problem-solving intervention can have beneficial effects for impulsivity (Gonzalez and Neander Reference Gonzalez and Neander2018; Abdullah et al. Reference Abdullah, Khalily, Ruocco and Hallahan2023). Lower levels of distress, including depressive and anxiety symptoms were noted with this study demonstrating a beneficial impact of CADS-S across a range of symptoms in the short-term. Of note, no participants provided with CADS engaged in any acts of self-harm either during the intervention or in the six-week post study intervention period. Employing, where appropriate culturally adapted interventions have previously been noted to be beneficial for a wide range of symptoms (affective and anxiety) (Abdullah et al. Reference Abdullah, Khalily, Ruocco and Hallahan2023; Miguel et al. Reference Miguel, Cecconi, Harrer, van Ballegooijen, Bhattacharya, Karyotaki, Cuijpers, Gentili and Cristea2024), and this study tentatively supports the cultural adaptation of psychotherapeutic strategies for this age cohort.
This intervention CADS was tailored to the cultural nuances of Pakistan, and whilst demonstrating significant benefits for a range of symptoms, these findings may not be generalisable to other regions, albeit different cultural adaptations could be employed as appropriate. Similarly, CADS was delivered to a relatively young population (16-20 years of age), with a relatively short-period of prior history of suicidal ideation and behaviours, and without a DSM-5 diagnosis of a mental disorder; and thus the study findings may not be generalisable to individuals with chronic suicidality or co-morbid mental health disorders. This study has a number of limitations. As self-report measures were utilised, there is a risk of bias, albeit both groups completed the same psychometric measures and measures employed have good reliability and validity indices, however the translated attentional sub-scale of the BIS had a relatively low Cronbach’s α. Individuals in the control arm received less face-to-face input and thus some of the efficacy reported could be related to a placebo effect from the level of engagement and rapport with clinicians in the CADS-S arm. We did not collect demographic or clinical data on individuals who did not participate in the trial and thus it is possible that individuals who declined to or who could not participate due to travel-related difficulties were not similar in some aspects (i.e. age) to those who engaged in the trial. The study only included male participants in education settings, with a narrow age range of 16–20 years old, and thus the effectiveness of this intervention in females, younger adolescents or older adults, or in individuals in non-education settings is not possible. The study had a relatively short follow-up period and thus it is unknown if this intervention would prove efficacious in the medium-long term. Caution is required with interpreting ηp 2 findings as it may potentially over-estimate effect sizes in small sample sizes. Finally, this trial was not a double-blind RCT and perhaps future studies should employ an active comparator arm to further ascertain the potential benefits of this intervention. A particular strength of this study was the high engagement rate, and level of expertise of the researchers in delivery of CADS. Future research should aim to replicate these findings in larger and more diverse samples to strengthen the evidence base for CADS, and perhaps across different jurisdictions. Given the recent decriminalisation of suicide in Pakistan, hopefully individuals engaging in self-harm or experiencing suicidal ideation will seek supports including psychotherapeutic supports (potentially including CADS) in the future.
Conclusion
This study demonstrated that CADS was an effective short-term intervention for reducing suicidal ideation, with additional benefits for impulsivity and psychological distress, with these benefits maintained at 6-week follow-up. Future studies should include an active comparator and greater diversity of participants (including age range and gender) to further elucidate the potential efficacy of this intervention.
Author contributions
Conceptualisation, M.A., M.T.K., B.H., study design, M.A., M.T.K., B.H.; data collection and analysis, M.A., M.T.K.; writing – original draft preparation, M.A., M.T.K., B.H.; writing – review and editing, M.T.K, B.H.; supervision, M.T.K, B.H. All authors have read and agreed to the published version of the manuscript.
Funding statement
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors have none to declare.
Ethical standards
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Departmental Ethics Committee “Board for Advance Studies and Research (BASR)” at the International Islamic University Islamabad (F. No. IIU/2021-Exams-6,511).
Informed consent
Informed consent was attained from all participants aged 18 and over. For participants under 18 years of age, informed consent was attained from participants’ parent(s) in addition to assent from study participants.
Appendix 1
Conceptual framework
Didactic-based intervention model
A novel intervention model was developed, grounded in Islamic principles, to address suicidal thoughts, impulsivity, and psychological distress among adolescents. This 12-session programme consists of two 45–50 minute sessions per week, incorporating cognitive behavioural techniques and behavioural activities.
Worksheet activities
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1. Practising selflessness and kindness
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2. Developing a consistent prayer routine
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3. Offering supplications (duas) for various occasions
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4. Cultivating good relationships with family and others
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5. Distinguishing between positive and negative actions
Intervention sessions
Session 1: Establishing rapport and introducing the concept of spiritual growth
Session 2: Encouraging selfless acts (with guided support for the experimental group)
Session 3: Exploring the importance of physical and spiritual cleanliness
Session 4: Engaging in activities promoting good deeds and self-reflection
Session 5: Understanding the significance of prayer, Quran recitation, fasting, and charity in daily life
Session 6: Reflecting on prayer and Quran recitation experiences
Session 7: Learning social etiquette and good manners
Session 8: Discussing positive interactions with family and others
Session 9: Understanding the value of inviting others to good deeds and righteousness
Session 10: Identifying and discussing positive and negative actions
Session 11: Exploring the concept of humility and servitude to God
Session 12: Reviewing progress and discussing the importance of consistent supplication.
Open access
