519241

research-article2014 Leigh-Hunt and Perry

IJOXXX10.1177/0306624X13519241International Journal of Offender Therapy and Comparative CriminologyNicholas

Article

A Systematic Review of Interventions for Anxiety, Depression, and PTSD in Adult Offenders

International Journal of Offender Therapy and Comparative Criminology 2015, Vol. 59(7) 701­–725 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0306624X13519241 ijo.sagepub.com

Nicholas Leigh-Hunt1 and Amanda Perry2

Abstract There is a high prevalence of anxiety and depression in offender populations but with no recent systematic review of interventions to identify what is effective. This systematic review was undertaken to identify randomised controlled trials of pharmacological and non-pharmacological interventions in adult offenders in prison or community settings. A search of five databases identified 14 studies meeting inclusion criteria, which considered the impact of psychological interventions, pharmacological agents, or exercise on levels of depression and anxiety. A narrative synthesis was undertaken and Hedges g effect sizes calculated to allow comparison between studies. Effect sizes for depression interventions ranged from 0.17 to 1.41, for anxiety 0.61 to 0.71 and for posttraumatic stress disorder 0 to 1.41. Cognitive behavioural therapy interventions for the reduction of depression and anxiety in adult offenders appear effective in the short term, though a large-scale trial of sufficient duration is needed to confirm this finding. Keywords depression, anxiety, posttraumatic stress disorder, offenders, interventions

Background The prevalence of anxiety and depression in offender populations is much higher than compared to the general population (Singleton, Lee, & Meltzer, 2000). Depending on 1University 2University

of Leeds, UK of York, UK

Corresponding Author: Nicholas Leigh-Hunt, Public Health Registrar, Academic Unit of Primary Care & Public Health, Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds LS2 9LJ, UK. Email: [email protected]

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study methodology and definitions used, rates in the UK have been estimated at between 30% and 75%, with higher rates in young, women, elderly, and remand prisoners (F. Harris, Hek, & Condon, 2007; Singleton, Meltzer, Gatward, Coid, & Deasy, 1997). A systematic review of the prevalence of mental disorders in prisoners in 12 western countries estimated the depression rates to be at 10% for men and 12% for women (Fazel & Danesh, 2002). The presence of depression is a major risk factor for self-harm and suicide; for example, one review suggests that the risk of suicide for individuals with an affective disorder is around 2%, four times higher than the general population (Bostwick & Pankratz, 2000), while another review looking at suicide rates in individuals diagnosed with major depression in nine developed countries estimated the risk to be 20 times higher (E. Harris & Barraclough, 1997). In prisoners, in addition to long sentence length, high criminal risk, lack of social support, bereavement of a close relative or friend, previous suicide attempts, a family history of suicide, impulsivity and alcohol or substance misuse, depression is a risk factor for suicide (Daigle, Labelle, & Côté, 2006). A survey in UK prisons found that 35% of men on remand and 20% of sentenced men had had suicidal thoughts in the past year; for suicidal attempts, the figures were 15% and 7% respectively. For women prisoners, 50% of those on remand and 34% of those sentenced had had suicidal thoughts in the past year; for suicidal attempts the figures were 27% and 16% respectively (Singleton et al., 1997). Among the 192 deaths in prison custody in the United Kingdom in 2012, there were 60 deaths due to self-inflicted causes, though not all of these individuals may have had suicidal intent (Ministry of Justice, 2013). Furthermore, anxiety and depression are associated with substance abuse and alcohol. High rates of alcohol and substance misuse are associated with mood disorders (Regier et al., 1990), and for women, depression often predates the onset of alcohol misuse (Marshall & Farrell, 2007). In prisoners, younger age, single marital status, physical and sexual abuse as a child, low education attainment, previous convictions and depression are associated with substance misuse (Butler, Levy, Dolan, & Kaldor, 2003; Singleton, Farrell, & Meltzer, 2003; Swogger, Conner, Walsh, & Maisto, 2011). Both anxiety and depression in offender populations may interact with socioeconomic factors such as unemployment, homelessness, and poor family relationships to increase the likelihood of offending behaviour (Modestin, Hug, & Ammann, 1997). There may also be an impact on other health conditions; depression has been found to increase the risk of developing coronary heart disease and subsequent mortality from it by 80% (Nicholson, Kuper, & Hemingway, 2006). Both anxiety and depression can be a substantial cause of disability, leading to absenteeism from work and reduction in gainful employment, and social withdrawal, which results from the associated stigma and loss of self-esteem and confidence. They are also known to have adverse effects on marital and family relationships; depression in a parent can lead to child neglect (Meltzer, Gatward, Goodman, & Ford, 2000; Ramchandani & Stein, 2003; Royal College of Psychiatrists, 2003). Guidelines exist for the treatment of the conditions in adults in the community (National Institute for Health and Clinical Excellence, 2005, 2009, 2011). However,

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interventions that are effective for the wider population in a community setting may not necessarily be applicable to or effective for offenders. This may be due to the underlying severity of the conditions, associated co-morbidities, and other social factors that ensure the conditions are refractory to treatment such as the ability to regain constructive employment, or the practicalities of undertaking such interventions in a prison environment. However, imprisonment or contact with the criminal justice system can present an opportunity to address the need of individuals who may have previously had poor access to health care. Identifying the most effective interventions for anxiety and depression could, therefore, help in addressing these needs and reducing the consequences of the conditions. Since offenders have some of the worst health outcomes in society, improving their health would help reduce health inequalities. Interventions aimed at reducing anxiety and depression in offenders can be aimed at improving either their detection or their treatment. Such examples include pharmacological interventions such as antidepressants; psychological interventions, such as counselling or cognitive behavioural therapy (CBT); or interventions aimed at modifying service provision and delivery, such as suicide prevention strategies or telepsychiatry. A review of the literature investigating the basis of evidence for mental health interventions in prisoners (Brooker, Sirdifield, & Gojkovic, 2007) did not identify any studies specifically looking at the treatment of affective disorders or posttraumatic stress disorder (PTSD). A more recent systematic review identified a number of interventions for mood disorders in young offenders (Townsend et al., 2010), though to our knowledge, this is the first systematic review of interventions for anxiety and depression in adult offenders.

Method This study was conducted using standardised guidance for systematic reviews as described in the Centre for Reviews and Dissemination 4th report and the Cochrane Collaboration Handbook (Centre for Reviews and Dissemination, 2008; Higgins & Green, 2008).

Databases and Search Strategy Five databases were searched using a search strategy (Appendix A) developed specifically for this review. Databases included Ovid MEDLINE: 1950 to January 2011; Embase: 1980 to January 2011; PsycINFO: 1950 to January 2011; CINAHL: 1981 to January 2011; Web of Science: 1950 to January 2011. A pragmatic decision was taken to use these databases following discussion with an information strategist based in an academic institution since they were likely to contain the majority of the randomised controlled trials (RCTs) in the subject area. References from the studies chosen for inclusion in the review were inspected to identify any other potential studies. Medical subject headings (MESH terms) were used to enhance the likelihood of relevant studies being identified by the search engine, with text word searching also carried out for each relevant concept. Searching was initially developed for the Ovid

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databases, and included the Cochrane Highly Sensitive Search Strategy for identifying randomised trials in MEDLINE filter to maximise sensitivity for RCTs (Lefebvre, Manheimer, & Glanville, 2008). The search strategy for CINAHL and Web of Science was modified due to the different thesaurus terms used and the inapplicability of this filter.

Study Identification and Inclusion Criteria Studies were assessed using a set of inclusion criteria that were applied to all identified papers by firstly screening abstracts, and secondly, reviewing the full paper copy of each study thought to be eligible for inclusion (Appendix B). Only studies published in English were considered for resource reasons, but there was no restriction with regard to country of origin. Eligible studies included (a) randomised controlled custodial or community trials considering interventions aimed at treating depression or anxiety; (b) adult prisoners or offenders of any ethnicity aged over 18 years of age of either sex. Interventions that were primarily aimed at other conditions that also assessed their impact on anxiety or depression were not excluded. The term “offender” included any individual involved in criminal activity, and “prisoner” was defined as any such individual detained in a secure correctional institution as a result of such activity or suspected activity; and (c) studies were included if participants were diagnosed with anxiety or depression either by internationally recognised criteria such as those of the International Classification of Diseases (ICD-10; World Health Organization, 2007) and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), or if a validated questionnaire was used when assessing outcomes. Where studies identified in the search process also considered PTSD, findings relating to that diagnosis were also included (Table 1). Our primary clinical outcome of interest was change in levels of anxiety, depression or PTSD (as rated on a validated questionnaire either by an observer or by a selfadministered questionnaire). Examples include the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Cognitive Somatic Anxiety Questionnaire (CSAQ; DeGood & Tait, 1987) or the Clinician-Administered Posttraumatic Stress Disorder Scale–1 (CAPS-1; Blake et al., 1990). We also included a number of secondary clinical outcomes: (a) cessation of medication due to clinical improvement, (b) reduction in symptom duration, and (c) reduction in the prevalence of the condition. Criminal outcomes of interest included reduced offending behaviour, reduced incarceration rates, or reduced substance misuse.

Data Extraction and Quality Assessment Data from the selected studies were extracted using a pre-designed data extraction form based on the Cochrane Effective Practice and Organisation of Care Review Group Data Collection Checklist and Data Abstraction Form (Cochrane Effective Practice and Organisation of Care Group, 2011a, 2011b). We assessed the quality of

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First time drink drivers

Holt, O’Malley, Rounsaville, & Ball, 2009, USA

Intervention 24 Control 18

Alcohol, substance abuse

Not stated

Intervention 24 Control 18

Intervention 10 Control 10

Not stated

Psychosis, learning disability, active treatment Illiteracy, psychosis, drug misuse treatment

Not stated

Intervention 5 Control 8

62

Psychosis IQ < 80

Intervention 16 Control 3

Intervention 41 Control 43

Not stated

Intervention 27 Control 17

Intervention 44 Control 45

Not stated

Intervention 24 Control 22

Intervention 13 Control 18

Intervention 24 Control 25

Not stated

Validated questionnaire + self-reported childhood abuse Clinical diagnosis or validated questionnaire Chronic illness or risk factors for it ± ≥40 years of age Emotionally disturbed + prison rule violation Not stated

Intervention 9 Control 9

Number completing

Intervention 9 Control 9

Number randomised

Learning disability

Exclusion criteria

Validated questionnaire

Inclusion criteria

Hilkey, Wilhelm, & Horne, 1982 USA

Gussak, 2007, USA

Cashin, Potter, Stevens, Davidson, & Muldoon, 2008, Australia Gottschalk, Covi, Uliana, & Bates, 1973, USA

Brick, Doub, & Perdue, 1966, USA

Bichescu, Neuner, Schauer, & Elbert, 2007, Romania Bradley & Follingstad, 2003, USA

Study and country

Table 1.  Summary of Participant Details for Included Studies.

80% M 20% F

All M

All M

All M

All M

All M

All F

17 M 1F

Gender

32 (10.5, —)

Intervention (—, 21-59) Control (—, 21-59) 28 (—, 24-48)

25 (6.15, —)

Intervention 48 Control 54

33 (—, 17-63)

37 (8, 34-54)

Intervention 69 Control 70

Mean age, years (SD, range)

84% White 9% Black 5% Hispanic

(continued)

Drink-driving offenders

Medium-security prison

Medium- and maximumsecurity prison

Not stated

53% White 47% Black

Forensic psychiatry institution

Maximum-security prison

Prison

Medium-security prison

Ex-political prisoners

Offender or prison characteristics

Not stated

Not stated

Not stated

62% Black 38% White

Romanian

Ethnicity

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Imprisoned for >3 years + resettled in USA Clinical diagnosis + education >6th grade Trauma experience

Nguyen, 2005, USA

Clinical diagnosis or BDI score ≥3 + No active treatment

Wilson, 1990, USA

Severe psychosis or depression, drug/alcohol use Psychosis, non-English speaker, brain impairment Not stated

Active self-harm psychosis brain disorder, illiteracy Non-speakers of English or Vietnamese Severe psychosis

Exclusion criteria

Number completing Intervention 13 Control 16

Intervention 30 Control 33 Intervention 36 Control 29 Not stated

Intervention 23 Control 21

Intervention 5 Control 5

Number randomised Intervention 20 Control 18

Intervention 30 Control 33 Intervention 39 Control 29 Intervention 56 Control 67

Intervention 27 Control 22

Intervention 5 Control 5

Note. M = male; F = female; BDI = Beck Depression Inventory.

Validated questionnaire + imminent release

Zlotnick, Johnson, & Najavits, 2009, USA

Richards, Beal, Seagal, & Pennebaker, 2000, USA Valentine & Smith, 2001, USA

Clinical diagnosis

Inclusion criteria

Maunder et al., 2009, UK

Study and country

Table 1.  (continued)

All M

All F

All F

All M

All M

All M

Gender

33 (8.0, 24-48)

35 (7.4, —)

Intervention 33 (9.1, —) Control 35 (9.8, —)

Intervention 60.5 (5.8, —) Control 35 (8.9, —)

Intervention 38 (11.6, —) Control 32 (10.9, -)

Mean age, years (SD, range)

Not stated

Maximum-security prison

Low-security prison

Low-medium-security prison

50% Black 38.5% White

46.9% White 32.7% Black 6.1% Hispanic

Maximum-security psychiatric prison

Ex-political prisoners

Vietnamese

79% White 18% Black

Medium-security prison

Offender or prison characteristics

Mostly White

Ethnicity

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the studies and rated them (high risk, unclear risk, low risk of bias) using the six domains of the Cochrane Risk of Bias tool (Higgins & Altman, 2008).

Data Analysis A narrative synthesis was undertaken and Hedges g effect sizes (Hedges, 1992) calculated to allow some comparison between studies. Calculation of Hedges g effect sizes allows standardisation, and therefore comparison of the differences in outcomes between groups of individuals in separate studies, which have used different means of measuring those outcomes. To carry out a calculation of a Hedges g effect size, the mean outcome, its standard deviation, and the number of subjects in each study needs to be known. The interpretation of Hedges g effect sizes are as follows: A positive effect size denotes a favourable outcome, a negative effect size an unfavourable outcome, whereas a value of zero identifies a lack of any effect. For nine of the papers (Bichescu, Neuner, Schauer, & Elbert, 2007; Bradley & Follingstad, 2003; Gottschalk, Covi, Uliana, & Bates, 1973; Hilkey, Wilhelm, & Horne, 1982; Maunder et al., 2009; Nguyen, 2005; Valentine & Smith, 2001; Wilson, 1990; Zlotnick, Johnson, & Najavits, 2009), the means, standard deviations, and number of individuals in the intervention and control groups necessary to calculate a Hedges g effect size were published, and therefore figures could be derived. Where an effect size was published, a re-calculation was made to ensure accuracy of figures, and if an alternative method of calculating effect sizes was given, a Hedges g calculation was undertaken providing all the summary statistics were available to do so. A metaanalysis was not undertaken as the studies considered different interventions and were too dissimilar to perform this. Three selected studies had incomplete data (Gussak, 2007; Holt, O’Malley, Rounsaville, & Ball, 2009; Richards, Beal, Seagal, & Pennebaker, 2000); authors were contacted by email requesting them to send missing data to enable effect sizes to be calculated. In another study (Cashin, Potter, Stevens, Davidson, & Muldoon, 2008), no standard deviations were published, but sufficient data were available for individual participants to allow the standard deviations to be calculated, and therefore effect sizes could be derived. A fifth study (Brick, Doub, & Perdue, 1966), which had incomplete data, was published in the 1960s, and as the authors could not be contacted, no attempt was made to calculate effect size (Table 2).

Results In total, 14 studies were included in the final review. Eleven of these were psychological interventions (Bichescu et al., 2007; Bradley & Follingstad, 2003; Gussak, 2007; Hilkey et al., 1982; Holt et al., 2009; Maunder et al., 2009; Nguyen, 2005; Richards et al., 2000; Valentine & Smith, 2001; Wilson, 1990; Zlotnick et al., 2009), two were pharmacological interventions (Brick et al., 1966; Gottschalk et al., 1973), and one was an exercise intervention (Cashin, Potter, Stevens, et al., 2008).

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No videotape prior to psychotherapy

Maunder et al., 2009, UK

Holt, O’Malley, Rounsaville, & Ball, 2009, USA

Hilkey, Wilhelm, & Horne, 1982, USA

Self-help booklets for anxiety and depression in envelope

Envelope with blank paper inside

Interactional therapy or coping skills

Prison and academic psychologists

Phenytoin 24 mg daily No art therapy

Phenytoin 300 mg daily

Group art therapy session ×1 weekly Videotape pre-training prior to psychotherapy ×1 session Group session of alcohol education

Academic psychologists Art therapists

Usual exercise facilities

Structured exercise sessions ×2 weekly

Academic psychologists and psychiatrists Clinical psychologists

Psychiatrists and psychologists Peer inmate instructors

Placebo capsules

Brick, Doub, & Perdue, 1966, USA Cashin, Potter, Stevens, Davidson, & Muldoon, 2008, Australia Gottschalk, Covi, Uliana, & Bates, 1973, USA Gussak, 2007, USA

Academic psychologists

No contact comparison group

Dialectical Behaviour Therapy ×9 group therapy sessions and ×9 writing sessions 600 mg tybamate ×3 daily

Bradley & Follingstad, 2003, USA

Academic psychologists

Delivered by

Psycho-education (PED), x1 session

Control

Narrative exposure therapy (NET) ×5 sessions

Intervention

Bichescu, Neuner, Schauer, & Elbert, 2007, Romania

Study

Table 2.  Summary of Interventions and Outcomes of Included Studies.

4 weeks

4 weeks

12 months

10 weeks

30 min

8 weeks

None post intervention None post intervention 8 weeks after psychotherapy

None post intervention None post intervention

1 week

6 months

Duration of follow-up

6 months

12 weeks

60 days

Not stated

10 weeks

Duration of intervention

(continued)

Hospital Anxiety and Depression Scale (HADS), Brief Symptom Inventory (BSI)

BDI

State–Trait Anxiety Inventory (STAI)

Gottschalk-Gleser Scales (GCS) BDI

Modified Kessler 10 tool (K10)

MMPI

Composite International Diagnostic Interview (CDI) BDI BDI, Trauma Symptom Inventory (TSI)

Assessment tools

709

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Psychologists

12 weeks

6-8 weeks

1 week

3 days

4 days

Duration of intervention

9 months

9 months

3 months

6 weeks

1 month

Duration of follow-up

Assessment tools

MMPI

Harvard Trauma Questionnaire (HTQ) Hopkins Symptom Checklist 25 (HSCL-25) Cognitive Somatic Anxiety Questionnaire (CSAQ) BDI, Clinical Anxiety Scale (CAS), PTSD Symptom Scale (PSS) CAPS-1

Note. BDI = Beck Depression Inventory; MMPI = Minnesota Multiphasic Personality Inventory; PTSD = posttraumatic stress disorder; CAPS-1 = Clinician-Administered Posttraumatic Stress Disorder Scale–1.

Wilson, 1990, USA

Individual supportive therapy Inventory

Clinical psychologists

Group Cognitive behavioural therapy ×3 sessions per week Group cognitive therapy ×14 sessions

Treatment as usual

Zlotnick, Johnson, & Najavits, 2009, USA

Academic psychologists

Waiting list control

Trauma Incident Reduction

Prison psychologists

No writing

Trauma writing

Academic psychologist

Delivered by

Richards, Beal, Seagal, & Pennebaker, 2000, USA Valentine & Smith, 2001, USA

Neutral writing

Control

Expressive writing for 30-60 min/day

Intervention

Nguyen, 2005, USA

Study

Table 2.  (continued)

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Most of the studies were from the last decade, though one dated back as far as 1966. The population groups in the studies were largely male, incarcerated, and aged between 20 and 40 years of age, though some studies considered groups of older individuals and ex-political prisoners. In half the studies, the ethnic background of the participants was not stated. When ethnic background was described, it was mixed for most of the studies. Eleven of the studies involved participants in the United States, whereas the other three studies were from the United Kingdom, Australia, and Romania. The Hedges g effect sizes were calculated for 10 studies and are shown for depression in Table 3, for anxiety in Table 4, and for PTSD in Table 5. One study (Bradley & Follingstad, 2003) reported summary statistics for individual components of a PTSD measurement tool but not an overall score, and therefore, an effect size for PTSD could not be calculated. Effect sizes for interventions for depression ranged from 0.17 to 1.41, for anxiety from −0.61 to 0.71, and for PTSD from 0 to 1.41. Confidence intervals for effect sizes for depression, anxiety, and PTSD were all wide.

Interventions for Depression Nine studies considered the effect of an intervention on depression (Table 3). Eight of them were carried out in the United States and one in Romania; two studies examined former political prisoners in the community, one looked at first-time drink drivers, while the rest studied individuals in medium and maximum-security prisons. Narrative Exposure Therapy (NET; Victims Voice, 2013) is a treatment based on cognitive behavioural exposure therapy aimed at individuals who have suffered severe and repeated trauma. The goal of treatment is to recall past experiences dating back to the earliest memories and then focus on the worst traumatic event they have experienced. In repeatedly talking about the latter, the intensity of the emotions associated with the event is thus reduced. Trauma incident reduction (TIR; Trauma Incident Reduction Association, 2013) is also a therapy which aims to reduce symptoms from previous traumatic events. The aim of the treatment is to allow an individual to re-experience the traumatic event within a safe environment and process the associated emotional and psychological issues. It is given over a much shorter time span than traditional cathartic therapies. Dialectical behaviour therapy (DBT) is a form of group therapy developed for individuals with borderline personality disorder (BPD), self-harming behaviour, or suicidal ideation. It comprises four modules, which aim to assist the individual to gain mindful awareness, the ability to experience current emotions and keep them in perspective; distress tolerance, the ability to tolerate and be rational about negative situations; emotion regulation, the ability to avoid labile or intense moods; and interpersonal effectiveness, the ability to be assertive and avoid interpersonal conflict. For depression, NET and TIR appear effective. In the study of NET in ex-political prisoners in the community (Bichescu et al., 2007), the treatment group experienced fewer depression symptoms as measured by the BDI at 6 months of follow-up compared to a control group who received psycho-education without NET. The reduction in BDI-assessed depression symptoms was also greater in the treatment than the

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MMPI

HSCL25 BDI

BDI

BDI

K10

MMPI

Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control 21.1 20.2 82.0 74.4

1.95

— — 16.15

12 14

15.8 17 23.8 21.9 76.3

M

— — 7.4 2.95 0.71 1.82 11.1 11 13.6 16.9

10.2 8 11.6 14.3 — 71.4 1.9 5.1

SD

16 13 52 2.74 30 0.59 56 67 5 5

9 9 13 18 22 — 5 8

N

6.82 232 1.86 33 9.7 17.5 61.2 56.4

5.8 15.3 11.7 18.6 65.2 19 10 13

M

— — 8.11 1.85 0.68 1.75 11.2 16.1 8.41 14.2

2.6 8.7 10.3 15.5 — 68 0 4.1

SD

Endpoint

16 13 52 4.44 30 0.58 56 67 5 5

9 9 13 18 22 — 5 8

N

4.8

— — 52 232 0.11 33 7.8

2.8 19 3

6.9

9.5

Difference in endpoint means

— — —   0.17 [−0.32, 0.66] 0.55 [0.19, 0.91] −0.37 [−1.49, 0.75]

1.41 [0.42, 2.40] 0.49 [−0.21, 1.20] —   0.85 [−0.24, 1.93]

Hedges g effect size (95% CI)

Note. CI = confidence interval; BDI = Beck Depression Inventory; MMPI = Minnesota Multiphasic Personality Inventory; K10 = Modified Kessler 10 tool; HSCL25 = Hopkins Symptom Checklist 25.

Wilson, 1990

Valentine & Smith, 2001

Holt, O’Malley, Rounsaville, & Ball, 2009 Nguyen, 2005

Brick, Doub, & Perdue, 1966 Cashin, Potter, Stevens, Davidson, & Muldoon, 2008 Gussak, 2007

BDI

Intervention Control Intervention Control Intervention Control Intervention Control

Bichescu, Neuner, Schauer, & Elbert, 2007 Bradley & Follingstad, 2003

BDI

Tool

Study

Baseline

Table 3.  Summary of Effectiveness of Interventions for Depression.

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CAS

CSAQ

HADS

Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control Intervention Control

Tool 75.1 67.9 2.01 2.11 42.61 43.02 12.61 13.67 24.14 23.07 61.1 56.2

M — — 0.84 0.87 10.17 9 4.23 3.08 11.97 14.07 15.1 16.7

SD

Baseline

18 20 24 18 45 45 20 18 36 29 53 67

N 66.2 64.6 1.7 2.29 39.89 41.38 10.89 13.87 22.62 15.69 46.3 55

M — — 0.87 0.75 9.22 9.55 4.1 4.19 11.35 10.39 15.6 21.9

SD

Endpoint

18 20 24 18 42 43 13 16 36 29 53 67

N

8.7

−6.93

2.98

1.49

1.6 — 0.59

Difference in endpoint means

—   0.71 [0.09, 1.32] 0.16 [−0.26, 0.58] 0.70 [−0.04, 1.43] −0.61 [−1.11, 0.12] 0.45 [0.08, 0.80]

Hedges g effect size (95% CI)

Note. CI = confidence interval; MMPI = Minnesota Multiphasic Personality Inventory; GCS = Gottschalk-Gleser Scales; STAI = State–Trait Anxiety Inventory; HADS = Hospital Anxiety and Depression Scale; CSAQ = Cognitive Somatic Anxiety Questionnaire; CAS = Clinical Anxiety Scale.

Richards, Beal, Seagal, & Pennebaker, 2000 Valentine & Smith, 2001

GCS

Gottschalk, Covi, Uliana, & Bates, 1973 Hilkey, Wilhelm, & Horne, 1982 Maunder et al., 2009

STAI

MMPI

Brick, Doub, & Perdue, 1966

Study

Table 4.  Summary of Effectiveness of Interventions for Anxiety.

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PSS (Global) CAPS-1

HTQ

CIDI

Intervention Control Intervention Control Intervention Control Intervention Control

Tool 11.8 11.4 1.97 1.97 24.6 20.3 69.4 64.4

M 1.6 3 0.56 0.67 11.9 12.5 16.7 21.3

SD

Baseline

9 9 30 33 53 67 27 22

N 5.4 9.9 1.85 1.85 8.5 15.8 45.9 46.7

M 1.3 4.1 0.56 0.66 9.7 13.9 30.7 28.3

SD

Endpoint

9 9 30 33 53 67 23 21

N

0.8

7.3

0

4.5

Difference in endpoint means

1.41 [0.42, 2.40] 0 [−0.49, 0.49] 0.60 [0.23, 0.96] 0.03 [−0.55, 0.61]

Hedges g effect size (95% CI)

Note. PTSD = posttraumatic stress disorder; CI = confidence interval; HTQ = Harvard Trauma Questionnaire; PSS = PTSD Symptom Scale; CAPS-1 = ClinicianAdministered Posttraumatic Stress Disorder Scale–1; CIDI = Composite International Diagnostic Interview.

Zlotnick, Johnson, & Najavits, 2009

Valentine & Smith, 2001

Bichescu, Neuner, Schauer, & Elbert, 2007 Nguyen, 2005

Study

Table 5.  Summary of Effectiveness of Interventions for PTSD.

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control group at 3 months of follow-up in a study of TIR in a low to medium-security prison for women (Valentine & Smith, 2001), though as reported standard deviations were larger than the absolute reductions observed this finding was not statistically significant. DBT and exercise appeared less effective for depression. In the study investigating its use in women prisoners who had suffered childhood physical and sexual abuse (Bradley & Follingstad, 2003), the reduction in BDI-assessed depression symptoms 1 week after the intervention was greater for the treatment group. However, reported standard deviations for symptom severity were nearly as large as or larger than the absolute reduction, so this finding lacks statistical significance. Psychological distress was reduced in a group of older male prisoners who received a 12-week exercise and health education programme in a maximum-security prison compared to a control group who did not (Cashin, Potter, Stevens, et al., 2008). The exercise routine consisted of two sessions a week tailored to the individual of cardiorespiratory endurance, strength and flexibility training, while the health education component centred on healthy diet and self. However, there was a considerable loss to follow-up even though the final assessment was at the end of the programme, which limited the assessment of its effectiveness. Group cognitive therapy did not appear effective at reducing symptom severity as assessed by clinical scales of the Minnesota Multiphasic Personality Inventory (MMPI) in 10 male prisoners in a maximum-security prison (Wilson, 1990). However, in this study there were large differences in symptom severity at baseline between the intervention and control groups, which may have minimised the apparent effect of the intervention.

Interventions for Anxiety Six studies considered the effect of an intervention on anxiety (Table 4); all but one was undertaken in the United States with the remaining one done in the United Kingdom. The institutions in which the participants resided included low, medium, and maximum-security prisons, as well as an institution for emotionally disturbed offenders; however, one study did not state the nature of the institution. TIR, self-help booklets, and phenytoin appeared effective for anxiety. In the study of TIR in incarcerated women (Valentine & Smith, 2001), the impact of the intervention on anxiety was also assessed using the Clinical Anxiety Scale (CAS). Symptoms assessed at 3 months of follow-up were reduced in the treatment group but not in the control; however, the numbers lost to follow-up in each group was not reported. One study (Maunder et al., 2009) that examined the use of self-help booklets in a medium-security prison measured anxiety symptoms using the Hospital and Anxiety Depression Scale (HADS; Zigmond & Snaith, 1983) at the end of a 4-week intervention period. Symptoms were reduced compared to baseline for the treatment group but

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not for the control, though standard deviations were larger than the observed reduction. Phenytoin is an anticonvulsant medication that was used in the past to treat symptoms of anxiety and depression, though it is not licensed now for this indication. Phenytoin was found to reduce anxiety in a study of its use in emotionally disturbed male prisoners (Gottschalk et al., 1973). Anxiety levels were assessed using the Gottschalk-Gleser content analysis method (Gottschalk & Gleser, 1969). Symptoms were reduced at the 6-months follow-up assessment in the intervention group but not in the control group, though standard deviations for anxiety scores were as large as the observed absolute reduction. One study looked at the effect of a videotape presentation aimed at dispelling myths around psychotherapy, misconceptions around mental illness, and explaining the purpose of psychotherapy and how to maximise the benefits of receiving it immediately prior to psychotherapy in a group of 90 male prisoners (Hilkey et al., 1982). When compared to psychotherapy alone, it was not found to be effective on levels of anxiety measured 8 weeks after the end of the psychotherapy sessions using the State–Trait Anxiety Inventory.

Interventions for PTSD Four studies considered the effect of an intervention on PTSD, all of which were carried out in the United States; one studied former Vietnamese political prisoners residing in the community, two studied individuals in low- to medium-security prisons, though for one study, the nature of the institution was not stated. While TIR and NET also appeared effective for PTSD, CBT was only found to be marginally effective on PTSD symptoms as assessed by CAPS-1 (Blake et al., 1990) in a study in a lowsecurity prison for women (Zlotnick et al., 2009). Expressive writing is a form of therapy that uses the written word as a means of self-disclosure and can be undertaken on an individual or group basis, with the therapist in person or remotely as over the Internet. It did not appear effective in a study considering its impact in a group of older former Vietnamese political prisoners (Nguyen, 2005). PTSD severity assessed 1 month after the intervention using the Harvard Trauma Questionnaire (Mollica et al., 1992) was equally reduced in both treatment and control groups. In the same study, expressive writing did not appear effective for depression. Depression severity, as measured by the Hopkins Symptom Checklist 25 (Parloff, Kelman, & Frank, 1954), was reduced by nearly the same amount in the control and the treatment groups. Similarly, no evidence of effectiveness was found for expressive writing on anxiety. In a study evaluating its impact in male prisoners in a maximum-security psychiatric prison (Richards et al., 2000), anxiety scores measured by the CSAQ 6 weeks after the intervention were reduced most in a no-writing group.

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Criminal Outcomes Criminal outcomes were only reported for two of the studies. In one study (Holt et al., 2009), the impact of one of three different group interventions on the percentage of those who continued drink-driving was measured; 28% of depressed individuals continued drink-driving compared with 32% of the non-depressed individuals, which was not a statistically significant difference. However, data were presented in a way that did not allow comparison between the different interventions and an effect size calculation. Another study (Zlotnick et al., 2009) looked at the re-incarceration rates in a group of women prisoners in a low-security prison who received CBT within a few months of release. Six of 27 (22%) women in the intervention group compared to 10 of the 22 (46%) women in the control group returned to prison within 6 months of follow-up, which was not a statistically significant difference. Neither this study nor any of the other studies considered outcomes such as improvement in quality of life or changes in use of health services.

Quality of Studies Generally, most of the studies reviewed had some form of possible bias and limitations (Appendix C). Studies’ sizes were small, and only three studies followed-up participants longer than 6 months after the intervention. Many lacked adequate descriptions about how individuals were selected to participate in the study or how they were allocated to the intervention or control groups. The majority had issues with blinding as a result of the use of self-reported questionnaires to assess outcomes and the researchers being actively involved in the treatment of the participants. However, depression and anxiety outcomes were measured in all of the studies using a specified validated measurement tool as opposed to relying on the subjective opinion of a researcher with regards to changes in the condition of participants. While funding for the studies was only disclosed for a few, the subject area is one that is unlikely to have undue influence or pressure from sponsors or prison systems on the outcomes.

Discussion To our knowledge, this is the first systematic review to evaluate interventions for the reduction of depression and anxiety in an adult offender population. Our main finding is that some of the interventions for the management of anxiety, depression, and PTSD in adults in the community recommended by the National Institute for Health and Clinical Excellence (NICE, 2005, 2009, 2011) appear effective in offenders in the short term. However, conclusions cannot be made about their long-term effectiveness due to the short follow-up times of the studies included in this review.

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The positive effect sizes identified in this review for CBT-type interventions are comparable to the finding of a Campbell Collaboration systematic review of CBT programmes for offenders: An odds ratio of 1.53 was identified for not reoffending within 12 months in individuals receiving CBT interventions compared to individuals not receiving such interventions; effect sizes in the individual studies in the review did not differ significantly according to whether the studies were randomised or not (Lipsey, Landenberger, & Wilson, 2007). A smaller effect size of 0.29 was identified for a non-systematic review of randomised and non-randomised programmes that followed a Risk–Need–Responsivity (RNR) model. The RNR mode is where the most intensive interventions are given to those offenders at highest risk of reoffending and delivered according to the offenders learning and intellectual abilities. The effect sizes for the individual programmes varied according to how closely they adhered to the RNR principles (Andrews & Bonta, 2010; Andrews et al., 1990). One of the major challenges that our review faced was the lack of detail about the context of the interventions in the individual studies; it is not possible to determine whether outcomes for CBT-type interventions varied according to risk of offending behaviour. This review identified three studies that used variants of CBT that support its use as an intervention for depression (Bichescu et al., 2007; Bradley & Follingstad, 2003; Wilson, 1990); one was included in a systematic review (Cuijpers, van Straten, Warmerdam, & Andersson, 2008) used to develop NICE guidelines for depression (National Institute for Health and Clinical Excellence, 2009). The other psychological therapies recommended by NICE for depression in adults in the community have not been studied in offenders, suggesting that there is a lack of evidence to support their use in this population subgroup. The study of the effect of exercise on depression (Cashin, Potter, Stevens, et al., 2008) supports the applicability to offenders of NICE recommendations on exercise for depression. However, the small study size and limited follow-up time did not allow a full evaluation of the effect of exercise, though its findings build on a previous cohort study (Cashin, Potter, & Butler, 2008). NICE guidelines also recommend the use of selective serotonin reuptake inhibitors (SSRIs) for depression in adults in the community, though this review did not identify any studies on their use in offenders. One study (Maunder et al., 2009) supported the use of individual non-facilitated self-help and was included in the evidence base for the NICE guidelines for anxiety (National Institute for Health and Clinical Excellence, 2011). However, this review did not find evidence to support the use of other low-intensity psychological interventions or high-intensity psychological interventions for anxiety in offenders. In addition, this review did not identify evidence supporting the use of benzodiazepines for anxiety in offenders, which is in keeping with guidelines for the management of anxiety in the community that do not recommend their use.

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Implications for Research This review identified six trials of problem-solving treatments with respect to depression, which were also considered in a review for young offenders (Townsend et al., 2010). In our review, depression was reported in four trials, three of which used the BDI and one used the HADS. In both our review for adult offenders and the Townsend review, there were small numbers of patients in the component studies which limits the conclusions that can be based upon the results. Therefore, our review and that of Townsend et al. (2010) suggest that a large single trial of CBT for offenders of all ages is needed, which should include proper evaluation and reporting of mood with an adequate follow-up period. Other recommendations for further research can be categorised in those that seek to address methodological limitations in this review and those that seek to address the gaps in the evidence base identified by this review. First, the validity of this review would be improved by widening the search strategy and inclusion criteria to identify any further published and unpublished studies, for example, those in languages other than English. The type of eligible study designs could be widened to include controlled before and after studies and interrupted time series studies that meet the Cochrane Effective Practice and Organisation of Care criteria (Cochrane Effective Practice and Organisation of Care Group, 2011b). Second, as most of the studies in this review involved male offenders, it would be useful to undertake new research on interventions involving female offenders, particularly since the prevalence of depression and anxiety is higher in women than in men (Singleton et al., 1997).

Implications for Practice This review, therefore, provides limited evidence that some interventions recommended by NICE guidelines for the management of depression, anxiety, and PTSD are effective in offenders in the short term. Due to the small number of studies identified, it does not provide evidence for all the interventions recommended by the NICE guidelines. It does suggest that some interventions not covered by the NICE guidelines might be effective, such as TIR. On the contrary, the review suggests that expressive writing is not effective in the short term but does not provide evidence on efficacy in the long term. In the light of these observations, NICE guidelines should continue to be used on a pragmatic basis unless new evidence comes to light. Other interventions should be used with caution due to the small evidence base and the lack of studies to support them in this review. In particular, the further use of expressive writing should be discouraged. Further research needs to be undertaken for specific subgroups of offenders, such as female offenders, those in the community, and around medication dosing, in addition to evaluating interventions that have already been implemented around delivery of mental health services and social support.

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Appendix A Search Strategy Participant   1. depression/   2. depress$   3. depressive disorder/   4. depressive disorder, major   5. depression, reactive   6. affective disorder   7. anxiety/   8. anxiety disorder   9. or/1-8 10. offender/ 11. offender$ 12. criminal/ 13. criminal$ 14. prisoners/ 15. prisoner$ 16. prisons/ 17. prison$ 18. jails/ 19. jail$ 20. gaol/ 21. gaol$ 22. or/10-21 23. 9 and 22 Interventions 24. intervention/ 25. intervention$ 26. treatments/ 27. treatment$ 28. therapies/ 29. ther$ 30. drug therapy 31. pharmaceutical preparations/ 32. pharmaceutical preparation$ 33. antidepressive agents/ 34. antidepressive drugs 35. antidepressant$ 36. anti-anxiety agents 37. tricyclic antidepressive agents 38. monoamine oxidase inhibitors/ 39. serotonin reuptake inhibitors/ 40. adrenergic uptake inhibitors/ 41. psychological therapies 42. counselling / 43. counsel$

52. group psychotherapy/ 53. community psychiatry/ 54. diagnosis/ 55. screening/ 56. prison reception screening tools 57. multidisciplinary assessment 58. suicide/ 59. suicide prevention 60. day care/ 61. delivery of health care/ 62. therapeutic day activities 63. Inreach teams 64. ambulatory care/ 65. ambulatory care facilities/ 66. inpatients/ 67. outpatients/ 68. community care networks/ 69. care programme approach 70. patient care/ 71. continuity of patient care/ 72. pastoral care/ 73. support workers 74. CARATS 75. mental health awareness training 76. listener schemes 77. family support 78. employment/ 79. education/ 80. exercise therapy/ 81. exercise$ 82. or/24-81 83. 23 and 82 Outcomes 84. outcome assessment (health care)/ 85. treatment outcome 86. process assessment (health care)/ 87. clinical outcomes 88. symptoms 89. quality of life 90. health services needs and demand/ 91. utilisation/ 92. criminal outcomes 93. or/84-92 94. 83 and 93 95. randomised controlled trial.pt. (continued)

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Appendix A  (continued) 44.  cognitive therapy/ 45.  behaviour therapy/ 46.  interpersonal psychotherapy 47.   problem-solving therapy 48.   short-term psychodynamic psychotherapy 49. computerised cognitive behavioural therapy 50.  nondirective therapy/ 51. psychotherapy

  96. controlled clinical trial.pt.   97. randomised.ab.   98. placebo.ab.   99. drug therapy.fs. 100. randomly.ab. 101. trial.ab. 102. groups.ab. 103. 95 or 96 or 97 or 98 or 99 or 100 or 101 or 102 104. exp animals/ not humans.sh. 105. not 104

Note. CARATS = Counselling, Assessment, Referral, Advice and Throughcare Services.

Appendix B

Records identified through database searching (n = 1188)

Additional records identified through other sources (n = 0)

Records after duplicates removed (n = 1151) Records screened (n = 1151)

One systematic review containing 6 studies Individual articles excluded: (n=5) Duplicate study (n=1) Non RCT (n=3) No baseline measure for depression (n=1)

Full-text articles assessed for eligibility (n = 44)

Individual studies included in qualitative synthesis (n = 14)

Studies included in quantitative synthesis (meta-analysis) (n = 0)

Records excluded (n = 1107)

Full-text articles excluded (n = 30) Duplicates in another journal (n=3) Non RCTS (n=4) Systematic review of non RCTs (n=2) Study participants not offenders (n=4) Participants under 18 (n=7) Systematic review, participants under 18 (n=1) Other diagnosis (n=5) Systematic review, other diagnosis (n=1) No outcome measure for depression (n=3)

PRISMA flow diagram (Moher, Liberati, Tetzlaff, & Altman, 2009). Note. RCT = randomised controlled trial.

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Bichescu, Neuner, Schauer, & Elbert, 2007 Bradley & Follingstad, 2003 Brick, Doub, & Perdue, 1966 Cashin, Potter, Stevens, Davidson, & Muldoon, 2008 Gottschalk, Covi, Uliana, & Bates, 1973 Gussak, 2007 Hilkey, Wilhelm, & Horne, 1982 Holt, O’Malley, Rounsaville, & Ball, 2009 Maunder et al., 2009 Nguyen, 2005 Richards, Beal, Seagal, & Pennebaker, 2000 Valentine & Smith, 2001 Zlotnick, Johnson, & Najavits, 2009 Wilson, 1990

Study High risk Unclear Unclear Low risk Unclear Unclear High risk Unclear Low risk Low risk Unclear Unclear High risk High risk

Low risk Unclear Unclear Low risk Unclear Unclear Low risk Unclear Low risk Low risk Unclear Unclear High risk High risk

Low risk High risk High risk High risk High risk High risk High risk High risk High risk High risk

High risk High risk High risk Low risk Low risk Low risk High risk High risk High risk High risk

Low risk High risk Unclear High risk

Low risk Low risk Low risk High risk High risk Low risk Low risk High risk Low risk Low risk

Low risk High risk High risk High risk

Low risk Low risk Low risk Low risk Low risk Low risk Low risk Low risk Low risk Low risk

Low risk Low risk Low risk Low risk

Selective reporting

Random Blinding of Blinding of Incomplete sequence Allocation participants outcome outcome generation concealment and personnel assessment data High risk High risk Low risk High risk

Reporting bias

Detection bias

Attrition bias

Selection bias

Performance bias

Appendix C Summary of Quality Assessments of Included Studies (Higgins & Altman, 2008).

Low risk Low risk Low risk Low risk Low risk Low risk Low risk Low risk Low risk Low risk

Low risk Low risk Low risk Low risk

Other bias

Other bias

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Authors’ Note This review was originally undertaken as a dissertation for a Master’s in Public Health at York University.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

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A systematic review of interventions for anxiety, depression, and PTSD in adult offenders.

There is a high prevalence of anxiety and depression in offender populations but with no recent systematic review of interventions to identify what is...
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